INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18, 2024 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in two out of five employee records reviewed.
Employee #1 was hired on October 2, 2017 and was promoted to Project Director on December 4, 2023 and was still in the position as of the date of the inspection. There is no plan for her current position.
Employee #2 was hired on August 8, 2022 and was promoted to Facility Director on December 4, 2023 and was still in the position as of the date of the inspection. There is no plan for his current position.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 704.11 (b) (1) the following procedures will be implemented:
Beginning 12/26/2024, the HR Generalist will ensure that each employee who is due for an annual evaluation also complete an "Annual Training Plan" with their immediate supervisor. The HR Generalist will notify each supervisor of this procedure and ensure its completion.
The direct supervisors will ensure that the staff they supervise complete an annual "Training Needs Assessment" and that the "Annual Training Plan" is completed with the employee during the time that the "Annual Evaluation" is due (hire date).
The HR Generalist will oversee the completion of this procedure when receiving the staff's "Annual Evaluations". She will ensure that each supervisor is submitting the "Annual Eval", "Annual Training Needs Assessment", and "Annual Training Plan". |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Employee #6 was hired as a Recovery Specialist on July 19, 2022 and was still in the position at the time of the inspection. Her training was due no later than July 19, 2024; however, no HIV/AIDS training was completed.
Employee #7 was hired as a Recovery Specialist on July 28, 2022. His training was due no later than July 28, 2024; however, neither training was completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 704.11 (c) (1), the following will be implemented:
Beginning on 12/26/2024, the HR Generalist will continue to give each new hire a training plan that includes the requirements of 6 hours of training for HIV/AIDS and 4 hours of training for TB/STD. The training plans will include the due date for each staff person. 1 year for counselor assistants, or counselors. 2 years for all other staff.
Each supervisor will ensure that the staff member completes the required trainings within the allotted time frame.
The HR Generalist will oversee the completion of this procedure as she receives a copy of all completed trainings from all staff. In addition, she will begin receiving annual training plans that will include the dates that the staff have completed the required trainings. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. The third floor bathroom's hot water was recorded at 136.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.6 (3), the following will be implemented:
Beginning on 12/26/2024, the maintenance staff will adjust the hot water temperature at each licensed facility, and ensure that it does not exceed 120 degrees. In addition, the Residential Program Supervisor will ensure that the water temperatures remain in compliance while completing the facility walk throughs once per month.
The Program Director will ensure that this procedure is completed during monthly supervision. |
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 within 12 hours.
Client #7 was admitted on June 26, 2024 and discharged on September 23, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.24 (a) (3), the following will be implemented:
Beginning on 12/26/2024, the Clinical Supervisor will ensure that each counselor is responsible to contact the clients emergency contact when they leave treatment prematurely, or are prematurely discharged for any reason within 12 hours of the clients departure. In the event that the counselor is not available to complete the contact, the Clinical Supervisor will make the contact. This contact will be documented in the clients record.
The Program Director will oversee the completion of this procedure during monthly supervision, and random chart audits. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to complete an annual written individual staff performance evaluation, a copy of which shall be reviewed and signed by the employee. The facility's policy and procedures manual states that an evaluation will be completed 90 days following a promotion.
Employee #1 was promoted to Project Director on December 5, 2023 and was still employed at the time of the inspection. A 90-day written performance evaluation was due no later than March 5, 2024; however, none was completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.26 (b) (3), the following procedure will be implemented:
Beginning on 12/26/2024, the HR Generalist will ensure that each employee receives a 90 day evaluation following their date of hire, or 90 days following a promotion. All supervisors are responsible to complete a 90 day evaluation with the staff they oversee. The 90 day evaluations are submitted to the HR Generalist following the completion of the documentation.
The Director of Compliance will oversee the completion of this procedure during quarterly meeting with the HR Generalist. |
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
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered in two out of two applicable records reviewed.
Client #8 was admitted on November 13, 2024 and was still active at the time of the inspection. He was prescribed Venlafaxine 37.5 mg capsule daily along with 150 mg capsule. There was no documentation of the medication being administered or the reason not administered on December 1, 6, 10 and 13, 2024.
Client #9 was admitted on December 4, 2024 and was still active at the time of the inspection. He was prescribed Insulin Lispro Kwikpen injection under skin three times daily. There was no documentation of the medication being administered as prescribed or the reason not administered on December 4th, 5th , 10th, and 15th (1 dose missed each day); 6th, 12th, 13th, 16th and 17th (non-administered); and 7th , 8th and 9th (2 doses missed each day).
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.32 (c) (1) (i), the following procedure will be implemented:
Beginning on 12/26/24, the Residential Program Supervisor will ensure that the Medication Administration Record indicates the reasons why a client has missed a prescribed medication on the daily basis. The Residential Program Supervisor will train the support staff and ensure their understanding of adding missed medication reasons to the MAR. In addition, the Residential Program Supervisor will review the MAR for each client on the weekly basis to ensure that the reason for not taking a medication is recorded.
The Program Director will oversee the progress of this procedure by reviewing the completed MARS on the monthly basis, and addressing any concerns with the Residential Program Supervisor during supervision. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in seven out of seven client records reviewed.
Client #1 was admitted on September 5, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was developed on September 6, 2024 with no frequency identified.
Client #2 was admitted on September 9, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 11, 2024 with no frequency identified.
Client #3 was admitted on September 11, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 13, 2024 with no frequency identified.
Client #4 was admitted on September 12, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 13, 2024 with no frequency identified.
Client #5 was admitted on June 6, 2024 and discharged on August 30, 202 4. A comprehensive treatment plan was developed on June 7, 2024 with no frequency identified.
Client #6 was admitted on June 10, 2024 and discharged on September 3, 2024. A comprehensive treatment plan was developed on June 12, 2024 with no frequency identified.
Client #7 was admitted on June 26, 2024 and discharged on September 23, 2024. A comprehensive treatment plan was developed on July 17, 2024 with no frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.52 (a) (2), the following will be implemented:
Beginning on 12/26/24, the Clinical Supervisor will ensure that each clinician completes the type of service and frequency on each treatment plan. The Clinical Supervisor will train all the clinicians regarding the regulation to record the type of service and frequency when completing a treatment plan.
The Program Director will oversee the progress of this procedure while meeting with the Clinical Supervisor for monthly supervision, and while completing random chart audits. |