INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on the facility failed to ensure cold food was at or below 40F. The facility did not have a mechanism to ensure the temperature of cold food was at or below 40F in the two refrigerators located in the hallway off of the kitchen.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
In an effort to address citation 705.7 (b) (5), the following will be implemented:
On 12/27/2023 the Residential Program Supervisor will purchase two thermometers to place in each of the refrigerators where one is missing.
The third shift support staff person will complete nightly temperature checks of all the refrigerators to ensure that the cold food is kept at or below 40F.
The Clinical Director will monitor this action step monthly during supervision with the Residential Program Supervisor. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits rom rooms and from the residential facility are unobstructed. The emergency exit on the third floor had a trash can and mop in front of the door.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (a) (1), the following will be implemented:
Beginning on 12/27/23, the Residential Program Supervisor will ensure that all stairways, hallways, and emergency exits are unobstructed during the daily house run. The Residential Program Supervisor will also inform all residents in the 3rd floor bedroom of the requirement to maintain an unobstructed emergency exit.
The Clinical Director will monitor this action step while completing a bi-weekly walk through of the facility. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection, the facility failed to clearly indicate exits by use of signs. The third-floor emergency exit had no sign.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (a) (1) (iv), the following will be implemented:
On 12/27/23 the Residential Program Supervisor will purchase and emergency exit sign and place it on the emergency exit door in the 3rd floor bedroom. In addition, the Residential Program Supervisor will ensure the the emergency exit sign remains on the emergency exit door while completing the daily house runs.
The Clinical Director will monitor this action step while completing bi-weekly walk throughs of the facility. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from March, 2023 through November, 2023, the facility failed to conduct an unannounced fire drill at least once a month. There were no fire drills conducted the months of September, October and November.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (d), the following will be implemented:
Beginning on 12/27/2023, the Residential Program Supervisor will ensure that a monthly fire drill is conducted on rotating shifts, that utilizes a different exit each month.
The Clinical Director will monitor this action step while conducting monthly supervision with the Residential Program Supervisor. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of inpatient client records, the facility failed to notify the emergency contact of the client leaving the facility against medical advice in three out of three applicable records reviewed.
Client #4 was admitted on October 16, 2023 and discharged on December 8, 2023.
Client #5 was admitted on October 31, 2023 and discharged on December 9, 2023.
Client #6 was admitted on October 23, 2023 and discharged on December 5, 2023.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the March 2, 2023 licensing inspection.
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Plan of Correction
In an effort to address citation 709.24 (a) (3), the following will be implemented:
Beginning on 12/27/2023, the Clinical Supervisor will train all staff on the procedures around contacting a clients identified emergency contact person if and when the client leaves treatment against medical advice, or is discharged prematurely. The training will include how to document the call in the call log of the clients record.
The Clinical Director will monitor the progress of this action step by conducting a monthly chart audit. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client records.
Client #7 was admitted on October 18, 2023 and discharged on November 6, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.33 (a), the following will be implemented:
Beginning on 12/27/23, counselors will ensure that their assigned client is notified in writing when the decision is made to therapeutically discharge them. The completion of this notice will be documented in the clients record.
The Clinical Supervisor will monitor the progress of this action step while completing monthly chart reviews and supervision. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six records reviewed.
Client #1 was admitted on October 11, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on October 24, 2023 and an update was due no later than November 24, 2023; however, it was not completed until December 14, 2023.
Client #2 was admitted on September 11, 2023 and was still active at the time of the inspection. A treatment plan update was completed on October 24, 2023 and the next update was due no later than November 24, 2023; however, it was not completed until November 28, 2023.
Client #4 was admitted on October 16, 2023 and was discharged on December 8, 2023. A comprehensive treatment plan was completed on October 16, 2023 and the next update was due no later than November 16, 2023; however, it was not completed until November 20, 2023.
These findings were reviewed with facility staff during the licensing inspection process.
This is a repeat citation from the March 2, 2023 licensing inspection.
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Plan of Correction
In an effort to address citation 709.52 (b), the following will be implemented:
Beginning on 12/27/23, each counselor will ensure that each of the assigned clients on their case load receive an updated treatment plan every 30 days - not to exceed the 30th day from the previous treatment plan.
The Clinical Supervisor will monitor the progress of this action step during the monthly chart reviews. In addition, the Clinical Supervisor will create a template with treatment plan due dates for each client to assist the clinical team in completing timely treatment plans. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in four out of four applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed at 7, 30 and 90 days following discharge.
Client #4 was admitted on October 16, 2023 and was discharged on December 8, 2023. There was no follow up documented.
Client #5 was admitted on October 31, 2023 and was discharged on December 9, 2023. There was no follow up documented.
Client #6 was admitted on October 23, 2023 and was discharged on December 5, 2023. There was no follow up documented.
Client #7 was admitted on October 18, 2023 and was discharged on November 6, 2023. There was no 7 day follow documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.53 (a) (11), the following will be implemented:
Beginning on 12/27/23, the Program Assistant will ensure that each client receives a follow up contact at 7 days, 30 days, and 90 days post discharge. The Program Assistant will ensure that each follow up contact is documented in the clients record.
The Clinical Director will monitor the progress of this action step by completing monthly chart reviews. The progress of this action step will be discussed in monthly supervision with the Program Assistant. |