INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal conducted on September 9-10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center Inc. Moffett House 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure project staff notified clients, in writing, of a decision to involuntarily terminate the client ' s treatment at the project in one of one applicable record.
Client #5 was admitted to the inpatient level of care on May 21, 2025 and was discharged August 10, 2025. There was no indication that client #5 received notification in writing of their termination from treatment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility failed to comply with 709.33 (a) related to notification of involuntary termination from treatment at the project. Based on these findings, all applicable staff will be re-trained in the involuntary discharge workflow. The clinical manager will review all discharges to assure that discharge paperwork adheres to the approved workflow. The clinical manager will conduct weekly chart audits for one month and monthly thereafter to ensure compliance. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in four of seven applicable records.
Client #1 was admitted to the inpatient level of care on June 17, 2025 and was active at the time of review. Client #1 had a comprehensive treatment plan created on June 18, 2025 that did not contain work being done as an integral part of the client ' s treatment.
Client #2 was admitted to the inpatient level of care on April 29, 2025 and was active at the time of review. Client #2 had a comprehensive treatment plan created on April 29, 2025 that did not contain work being done as an integral part of the client ' s treatment.
Client #3 was admitted to the inpatient level of care on May 9, 2025 and was active at the time of review. Client #3 had a comprehensive treatment plan created on May 9, 2025 that did not contain work being done as an integral part of the client ' s treatment.
Client #6 was admitted to the inpatient level of care on January 16, 2025 and was discharged June 23, 2025. Client #6 had a comprehensive treatment plan created on January 16, 2025 that did not contain work being done as an integral part of the client ' s treatment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.53 (a) related to work as treatment. The Project Director and the Clinical Manager and Director will provide education to all staff regarding inclusion of the therapeutic value of work in treatment planning and collaborate with each patient to assure that the work is in line with their treatment goals. Each treatment plan date will be reviewed to ensure compliance with the addition of work as an integral component of their treatment and rehabilitation process. The Clinical Manager will review and sign off on all treatment plans in the EHR. The Clinical Manager will conduct weekly chart audits for two months and monthly thereafter to ensure compliance. The Project Director will review these audits with the Clinical Manager in weekly supervision. |