INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 16, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Gate House for Women, 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(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's policy and procedures and administrative documentation, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
On March 14, 2012, the facility's policy and procedures were reviewed. Per the agency policy and procedure, "a fiscal year training calendar will be kept by Program Directors indicating all staff training topics, dates, and presenters, etc. This information will be submitted by the end of the fiscal year to the Chief Executive Officer for use in developing an overall annual training assessment report." On March 15, 2012, the project/facility director was requested to provide documentation of the overall training plan. The facility's annual report was presented, however, it did not include an overall training plan for the 2011/2012 overall training plan.
The project/facility director was interviewed on March 15, 2012. The project/facility director confirmed that an overall plan for addressing training needs was not completed.
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Plan of Correction
Utilizing the information gathered from the annual assessments of staff training needs and the Annual Evaluation of the Overall Training Program, the Project Director will develop the Overall Training Plan for the upcoming training year. The Overall training plan will include training subjects, potential trainers and dates of trainings. As trainings are scheduled they will be posted on the already existing staff training calendar.
The step taken to assure ongoing compliance, the overall training plan will become part of the annual report which is completed on an annual basis at the end of each training/fiscal year.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on the physical plant inspection, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers.
The findings include:
The physical plant inspection took place on March 16, 2012. At 1:20 p.m. the dumpster was observed to be uncovered. The clinical supervisor confirmed this finding.
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Plan of Correction
Clinical Supervisor will contact the trash removal company to notify them of the need to have the dumpster replaced with the lids covering the dumpster each and every time. To ensure the dumpster is being covered, the house manager will inspect on a weekly basis. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on the physical plant inspection, the facility failed to provide an exhaust fan or window in a bathroom.
The findings include:
The physical plant inspection was conducted on March 16, 2012. The second floor front bathroom was observed to have an inoperable exhaust fan. The clinical supervisor confirmed this finding.
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Plan of Correction
The second floor front bathroom is currently being renovated, the exhaust fan is included in the renovation. The exhaust fan will be operable at the completion of the bathroom renovation on 4/30/12. The building committee will follow up with a punch list inspection following the completion of renovation.
As part of the weekly maintenance walk-thru by the House Managers bathroom fans as well as other appliances will be inspected to assure they are functioning properly. |
705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on the review of the facility's policy and procedures, the facility failed to document written procedures for staff and residents to follow in case of an emergency that included provisions for the evacuation and transfer of residents impaired by alcohol or other drugs.
The findings include:
The facility's policy and procedures were reviewed on March 14, 2012. The project/facility director was asked to provide the procedure for the evacuation and transfer of residents that are impaired by alcohol or other drugs. The project/facility director was unable to provide written procedures. The finding was not disputed.
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Plan of Correction
The project director and clinical supervisors will meet to revise the current policy/procedure in accordance with the standard, which will address the evacuation of residents that are impaired by the use of Alcohol or other drugs. The policy will include staff involvement, emergency versus non-emergency, the resident's safety, level of care determination, the referral process, and transportation. These procedures will be communicated to all staff members in at a training session on all shifts. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill log it was determined that the facility failed to conduct a fire drill during sleeping hours at least every six months.
The findings were:
A review of the fire drill log was conducted on March 15, 2012. The last documented fire drill during sleeping hours occurred in December 22, 2011 at 1:45 a.m. Prior to that drill, the last drill during sleeping hours was conducted on September 12, 2010 at 12:28 a.m. There was a period of fourteen months between fire drills conducted during sleeping hours. A discussion with the clinical supervisor on March 16, 2012 confirmed that no fire drill was conducted during sleeping hours from September 12, 2010 until December 22, 2011. The finding was not disputed.
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Plan of Correction
The Clinical Supervisor will develop a schedule for monthly fire drills that includes all required testing times such as, sleeping hours, days, and evening shifts. The house manager will be responsible for implementing the fire drill schedule each month. To ensure compliance, the Clinical Supervisor will monitor the schedule on a quarterly basis. |
709.24(a)(2) 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:
(2) Treatment models utilized by the project.
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Observations
Based on the review of the facility's policy and procedures, the facility failed to document treatment models and definitions in the agency manual.
The findings include:
The facility's policy and procedures were reviewed on March 14, 2012. It was noted during the inspection that the treatment models utilized were not documented or defined in the agency manual. The project/facility director was asked to provide the required documentation. The materials presented were treatment methods and not defined treatment models.
The finding was confirmed by the project/facility director and clinical supervisor on March 14, 2012.
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Plan of Correction
The Clinical Supervisors have documented evidence based treatment models that are utilized in the treatment process. Prior to being placed in the manual, the project director has reviewed and approved. The clinical supervisors will supervise the clinical staff in the utilization of evidence based treatment models. |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
Based on the review of the facility's policy and procedure, the facility failed to document an inventory of client medications.
The findings include:
The facility's policy and procedures were reviewed on March 14, 2012. Based on the facility's policy, "The inventory of stored medication is done at the time of the quarterly inspection by the Clinical Supervisor and designated staff." Staff were requested to provide the quarterly inventory of stored medication. The staff were unable to provide the required documentation and stated that they were not conducting inventories of client medications.
The clinical supervisor confirmed this finding.
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Plan of Correction
The project director and clinical supervisors will meet to revise all medication policy and procedures to address all areas of 709.32 Medication Control to include the policy and procedure of inventory. The clinical supervisors will meet with all staff to educate them on the procedures which will include the ongoing inspection and inventory of all incoming medication. Clinical Supervisors will ensure compliance during their quarterly inspection of the medication storage area. |
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 a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one record reviewed.
The findings include:
Seven client records were reviewed on March 16 2012. One client was involuntarily discharged and required the facility to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project. There was documentation of a notification of termination letter in client record # 1, however, it was unable to be determined if the client received a copy of the termination letter.
Client # 1 was admitted to the program on August 12, 2011 and was involuntarily discharged on August 21, 2011. The client record contained a termination letter, however, there was no indication that the client received a copy. There was no place for the client to sign off on the notification.
This finding was confirmed by the clinical supervisor.
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Plan of Correction
The Clinical Supervisors have met and updated the Notification of Involuntary Termination Notice to include signature lines for the client and witness. The notice also includes documentation as to whether the client has received or declined a copy of the notice. The project director has approved the revision. The clinical supervisors will educate the staff on the use of this notice during the weekly staff meeting, and ensure compliance during monthly closed chart reviews. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to inform the client of their right to request reconsideration of the decision for their termination of treatment in one of one client record.
The findings include:
Seven client records were reviewed on March 16, 2012. One client was involuntarily discharged and required the facility to allow the client to have the opportunity to request reconsideration of the decision to terminate treatment in client record # 1.
Client # 1 was admitted to the program on August 12, 2011 and was involuntarily discharged on August 21, 2011. The client record contained a termination letter in the record that included the client's right to request reconsideration of the decision to terminate treatment; however, there was no indication that the client received a copy. There was no place for the client to sign off on the notification.
The finding was confirmed by the clinical supervisor.
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Plan of Correction
The Clinical Supervisors have met and updated the Notification of Involuntary Termination Notice to include instructions on the right to request reconsideration. The project director has approved the revision. The clinical supervisors will educate the staff on the use of this notice during the weekly staff meeting, and ensure compliance during monthly closed chart reviews. |