INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 2, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, The Gate House for Men was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.7 (b) (4) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on a physical plant inspection conducted on September 2, 2020, the facility failed to ensure that storage areas for food were free of food particles, dust and dirt as it was observed that there was an uncovered bowl of cooked eggs with a fork in it sitting in the refrigerator.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.7 the following will be implemented:
Beginning 10/01/2020 the Residential Program Supervisor will ensure that there is no food stored in the refrigerator without being covered and dated.
The Clinical Director will monitor the progress of this implementation by conducting a weekly facility inspection. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The project failed to obtain an informed and voluntary consent from the client prior to the disclosure of information contained in the client record in one of seven client records reviewed.Client #4 was admitted on October 11, 2019 and was discharged on January 13, 2020. The client record contained a progress note regarding a family session that occurred on November 2, 2019 which documented contact with two of the client's family members. There were no release of information forms signed by the client that allowed disclosures to the two family members.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28 the following will be implemented.
Beginning on 10/01/2020 all clinicians will ensure that a confidentiality disclosure form is completed in its entirety, including the clients signature prior to conducting a family session.
The Clinical Director will monitor the progress of this correction during the monthly chart reviews. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The project failed to include the name of the person, agency, or organization to whom disclosure would be made to on an informed and voluntary consent to release information form in one of seven client records reviewed.Client # 7 was admitted on February 6, 2020 and was discharged on April 1, 2020. The record contained three consent to release information forms, all signed and dated March 10, 2020 by the client, that did not document the name of person, agency or organization to whom disclosures would be made to.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28 the following will be implemented:
Beginning on 10/01/2020 all staff completing confidentiality forms with clients will ensure that the form is completed in its entirety. The staff will specifically ensure that the person's name, agency, or organization that the client agrees to disclose information to, is documented on the form with the clients signature.
The Clinical Director will monitor the progress of this correction through monthly chart reviews. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The project failed to keep maintain the specific information to be disclosed within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of seven client records reviewed. Additionally, the facility failed to document any specific information to be disclosed on releases of information in three of seven client records reviewed.Client #3 was admitted on June 3, 2019 and was discharged on October 3, 2019. A consent to release information form for a dental practice, signed by the client on June 18, 2019, did not document the specific information to be disclosed. Client #4 was admitted on October 11, 2019 and was discharged on January 13, 2020. A consent to release information form for a sponsor, signed by the client on October 10, 2019, did not document the specific information to be disclosed. Client #5 was admitted on June 14, 2019 and was discharged on September 19, 2019. A consent to release information form for a health care provider, signed by the client on July 31, 2019, did not document the specific information to be disclosed. Client #6 was admitted on November 14, 2019 and was discharged on March 18, 2020. A consent to release information form for a probation and parole agency, signed by the client on November 17, 2019, allowed for the disclosure of the medications prescribed to the client and follow-up information about the client, which is outside the limits of 4 Pa Code 255.5.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28 the following will be implemented:
Beginning 10/13/2020, all staff completing confidentiality forms will ensure that the form is completed in its entirety, to include the specific information being disclosed.
The Clinical Director will monitor the progress of this correction during monthly chart reviews. In addition, the Clinical Director will ensure that all future disclosures remain within the limits established by 4 Pa. Code 255.5. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The project failed to ensure that the purpose of disclosure was included on an informed and voluntary consent to release information form in two of seven client records reviewed.Client #3 was admitted on June 3, 2019 and was discharged on October 3, 2019. A consent to release information form for a dental practice, signed by the client on June 18, 2019, did not document the purpose of the disclosure.Client #5 was admitted on June 14, 2019 and was discharged on September 19, 2019. A consent to release information form for a health care provider, signed by the client on July 31, 2019, did not document the purpose of the disclosure.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28 the following will be implemented:
Beginning 10/01/2020 all staff completing a confidentiality form will ensure that the form is completed in its entirety. Specifically, the staff will ensure that the purpose of the disclosure is documented on the form.
The Clinical Director will monitor the progress of this correction during the monthly chart reviews. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
The project failed to implement their written procedures regarding the documentation of the administration of all medications used by clients in three out of seven client records reviewed.Client #2 was admitted on January 13, 2020 and was discharged on January 31, 2020. The client missed dosages of prescribed medications on January 23, 2020 and January 24, 2020; however, the reasons for the missed dosages were not documented in the record.Client #3 was admitted on June 3, 2019 and discharged on October 3, 2019. The client missed dosages of prescribed medications on June 22, 2019, June 23, 2019, and June 29, 2019; however, the reasons for the missed dosages were not documented in the record.Client #4 was admitted on October 11, 2019 and discharged on January 13, 2020. The client missed dosages of prescribed medications on January 1, 2020 and January 11, 2020; however, the reasons for the missed dosages were not documented in the client record.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.32 the following will be implemented:
Beginning 10/01/2020, when clients miss their doses of medications, the reason for the missed dose will be documented on the clients medication administration record. The Residential Program Supervisor will ensure that this correction is implemented.
The Clinical Director will monitor the progress of this correction by completing monthly reviews. |