INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 31, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gate House Behavioral Health Services 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(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 one of five employee records reviewed, the facility failed to provide documentation of staff persons and volunteers receiving 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 within the regulatory timeframe. Employee # 5 was hired as a counselor on .March 23, 2020 and was still in this position at the time of the inspection. Employee # 5 did not receive HIV/AIDS/TB/STD training within the first year of employment.These findings were reviewed with 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 4/26/2021, the Program Coordinator will maintain a record of all employee training requirements and training certificates of completion.
The Clinical Supervisor will ensure that each newly hired clinician receive the required 6 hours of HIV/AIDS training, and at least 4 hours of tuberculosis, STD's, and other health related topics from DDAP's approved curriculum within their first year of employment.
The Clinical Director will monitor this requirement during monthly supervision with the Clinical Supervisor and Program Coordinator. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on one of five employee records reviewed, the facility failed to provide documentation the facility director having at least 12 clock hours of training annually.Employee # 2 was hired as the facility director on June 4, 2018 and was still in this position at the time of the inspection. The facility's training year was reviewed was from July 1, 2019 through June 30, 2020. Employee #2's employee record did not document the required 12 hours of annual training for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 704.11 (d) (2) the following will be implemented:
Beginning on 4/26/2021, the Clinical Director will ensure that he completes a minimum of 12 training hours per fiscal year.
The Executive Director will monitor the progress of this action step during monthly supervision. |
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
Based on one of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the name of the person, agency or organization to whom disclosure is made. Client # 13 was admitted on August 4, 2020 and was discharged on December 9, 2020. An informed and voluntary consent from the client for the disclosure of information signed and dated on August 4, 2020 did not provide the name of the person, agency or organization to whom disclosure is being made. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28 (c) (1) the following will be implemented:
Beginning 4/26/2021, the Clinical Supervisor will ensure that each client consent form is completed in its entirety, to include the name of the person, agency or organization to whom the disclosure is made.
The Clinical Director will monitor the progress of this action step during monthly supervision with the Clinical Supervisor. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on four of seven client records reviewed, the facility failed to provide counseling services on a regular and scheduled basis to include individual counseling at least twice weekly in client records # 9, 10, 12, and 13.Client # 9 was admitted on February 9, 2021 and was still active at the time of the inspection. After a review of progress notes and client record of service, there was one individual session documented the weeks of February 9-16, March 9-16, ,and March 23-30. There were no individual sessions the week of February 16-23.Client # 10 was admitted on December 30, 2020 and was still active at the time of the inspection. After a review of progress notes and client record of service, there was one individual session documented the weeks of January 6-13, January 27-February 3, February 17-24, March 10-17, and March 24-30. Client # 12 was admitted on August 10, 2020 and was discharged on September 16, 2020. After a review of progress notes and client record of service, there was one individual session documented the week of August 31-September 7. There were no individual sessions the weeks of August 17-24 and September 7-14.Client # 13 was admitted on August 4, 2020 and was discharged on December 9, 2020. After a review of progress notes and client record of service, there was one individual session documented the weeks of August 18-25, August 26-September 1, September 1-8, September 15-22, October 13-20, November 10-17, and November 17-24. There were no individual sessions the weeks of November 24-December 1 and December 1-8.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.82 (d) (1) the following will be implemented:
Beginning on 4/26/2021, the Clinical Supervisor will ensure that the Partial Hospitalization Program clients are receiving two individual sessions per week. In the event that the client does not attend their scheduled individual sessions twice per week, the assigned clinician will document the clients absence in a DAP note.
The Clinical Supervisor will monitor this progress while auditing client charts monthly. |
709.82(d)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(2) Group counseling, at least twice weekly.
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Observations
Based on four of seven client records reviewed, the facility failed to provide counseling services on a regular and scheduled basis to include group counseling at least twice weekly in client records # 9, 12, 13 and 14.Client # 9 was admitted on February 9, 2021 and was still active at the time of the inspection. After a review of progress notes and client record of service, there were no group sessions the weeks of February 9-16 and 16-23.Client # 12 was admitted on August 10, 2020 and was discharged on September 16, 2020. After a review of progress notes and client record of service, there were no group sessions the weeks of August 10-17, 17-24.Client # 13 was admitted on August 4, 2020 and was discharged on December 9, 2020. After a review of progress notes and client record of service, there was one group session documented the week of November 24-December 1.Client # 14 was admitted on August 26, 2020 and was discharged on September 16, 2020. After a review of progress notes and client record of service, there were no group sessions documented the week of August 26-September 2.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.82 (d) (2) the following will be implemented:
Beginning on 4/26/2021, the Clinical Supervisor will ensure that the Partial Hospitalization Program clients each receive four groups per week. In the event that the client fails to attend the scheduled group session, the clinician will document the client's absence in the clients chart.
The Clinical Supervisor will monitor this progress during the monthly chart audits. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on four of five applicable client records reviewed, the facility failed to provide documentation of case consultation notes in accordance with the facility policy and procedure. Per the facility manual, case consultations are to occur every 30 days, after a change in level of care, and at discharge.Client # 9 was admitted on February 9, 2021 and was still active at the time of the inspection. A case consultation was due to occur no later than March 9, 2021. There was no documentation of a case consultation in the client record. Client # 10 was admitted on December 30, 2020 and was still active at the time of the inspection. A case consultation was due to occur no later than January 30, 2021. There was no documentation of a case consultation until March 1, 2021. Client # 12 was admitted on August 10, 2020 and was discharged on September 16, 2020. A case consultation was due to occur no later than September 15, 2020. There was no documentation of a case consultation until September 1, 2020.Client # 13 was admitted on August 4, 2020 and was discharged on December 9, 2020. A case consultation was due to occur no later than September 4, 2020 and October 4, 2020. There was no documentation of a case consultation until October 28, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.83 (a) (4) the following will be implemented:
Beginning on 4/26/2021, the Clinical Supervisor will ensure that case consults are completed within the following intervals: Every 30 days, each time their is a change in the clients level of care, and at discharge. The Clinical Supervisor will begin to utilize a tracking form to assist her in recognizing due dates for case consults. Case consults will be completed during the weekly staff meeting, prior to the due date.
The Clinical Director will monitor the progress of this action step during monthly supervision. |
709.83(a)(11) LICENSURE Client records
709.83. 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 two of three applicable discharged client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 30, 60, and 90 days post discharge and documented on the follow-up form.Client # 13 was admitted on August 4, 2020 and discharged on December 9, 2020. There was no follow-up information documented in the client record. Client # 14 was admitted on August 26, 2020 and discharged on September 16, 2020. There was no follow-up information documented in the client record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.83 (a) (11) the following will be implemented:
Beginning on 4/26/2021, the Program Coordinator will conduct follow up contacts for all clients post discharge at the following intervals: 30, 60, and 90 days. The Program Coordinator will document each follow up contact.
The Clinical Director will monitor this action step monthly during supervision. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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 four of seven client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan to include type and frequency of treatment and rehabilitation services in client records # 2, 3, 4, and 7. Client # 2 was admitted on October 14, 2020 and was still active at the time of the inspection. The comprehensive treatment plan developed on October 14, 2020 and subsequent treatment plan updates on November 13, 2020 and January 4, 2021 did not include type and frequency of treatment and rehabilitation services. Client # 3 was admitted on August 27, 2020 and was still active at the time of the inspection. The comprehensive treatment plan developed on August 27, 2020 and subsequent treatment plan updates on September 17, 2020, November 12, 2020 and January 8, 2021 did not include type and frequency of treatment and rehabilitation services. Client # 4 was admitted on December 28, 2020 and was still active at the time of the inspection. The comprehensive treatment plan developed on December 28, 2020 and subsequent treatment plan updates on January 12, 2021 and March 12, 2021 did not include type and frequency of treatment and rehabilitation services. Client # 7 was admitted on August 5, 2020 and was discharged on October 14, 2020. The comprehensive treatment plan developed on August 5, 2020 indicated Individual sessions for one hour but did not provide frequency of services. A treatment plan update on August 27, 2020 indicated treatment "4 weeks in a row" but did not provide type or frequency of the treatment.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.92 (a) (2) the following will be implemented:
Beginning on 4/26/2021 the clinicians will ensure that each client's treatment plan includes the type and frequency of treatment and rehabilitation services.
The Clinical Supervisor will monitor the progress of this action step monthly while auditing client records, and during supervision with clinicians. |
709.93(a)(11) LICENSURE Client records
709.93. 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 three of three applicable discharged client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 30, 60, and 90 days post discharge and one week after a referral documented on the follow-up form.Client # 5 was admitted on March 5, 2020 and discharged on November 11, 2020. There was no follow-up information documented in the client record. Client # 6 was admitted on June 10, 2020 and discharged on September 16, 2020. There was no follow-up information documented in the client record. Client # 7 was admitted on August 5, 2020 and discharged on October 14, 2020. There was no follow-up information documented in the client record. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the February 21, 2020 inspection.
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Plan of Correction
In an effort to address citation 709.93 (a) (11) the following will be implemented:
Beginning on 4/26/2021, the Program Coordinator will conduct follow up contacts for all clients post discharge at the following intervals: 30, 60, and 90 days. The Program Coordinator will document each follow up contact.
The Clinical Director will monitor this action step monthly during supervision. |