INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 19, 2018 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Two personnel records were reviewed for the counselor assistant position on March 15, 2018, for the licensing renewal inspection conducted on March 19, 2018. The facility failed to fully document the provision of direct observation for employee records # 3 and 5. Employee # 3 was hired by the project on 6/22/15, and then started employment as a high-school diploma level counselor assistant on 8/29/16. The employee was then promoted to the counselor position on 2/5/18, upon completion of a qualifying bachelor's degree. The employee required direct observation and close supervision for the first 12 months of employment in the counselor assistant position. Weekly supervision notes were reviewed for the period of 3/17/17 - 8/25/17. The facility failed to demonstrate that weekly close supervision included 1 hour of direct observation at least once per week. Employee # 5 was hired by the facility on 11/14/16 as a high-school diploma level counselor assistant. The employee required direct observation and close supervision for the first 12 months of employment in the counselor assistant position. The employee received 7 months of close supervision while previously employed as a counselor assistant with another project. Upon hiring the employee, this facility was required to conduct a minimum of 5 months of close supervision, which was to include direct observation. Weekly supervision notes were reviewed for the period of 2/24/17 - 4/14/17. The facility failed to demonstrate that weekly close supervision included 1 hour of direct observation at least once per week. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 704.9 (c), the following will be implemented.
In the event that a counselor assistant is employed at the Gate House for Women, the Clinical Director will ensure that documented direct observed supervision is conducted weekly for the first year of employment for high school level counselor assistants, and for the first 6 months of employment for bachelor level counselor assistants.
This correction will be implemented by 4/20/2018. The Program Administrator will oversee the implementation of this plan of correction.
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704.11(a)(4) LICENSURE Evaluation of Overall 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:
(4) An annual evaluation of the overall training plan.
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Observations
A licensing renewal inspection was conducted on March 19, 2018. The facility's training year was from June 30th, 2016 through July 1st, 2017. The facility failed to provide documentation of an annual evaluation of the overall training plan for the 2016-2017 training year. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 704.11 the following will be implemented.
The Program Administrator and the Human Resources Director will ensure that an evaluation of the organization wide training plan is completed this year by July 16 2018.
The Program Administrator will ensure that this plan of correction is adhered to annually, beginning with the evaluation for the 2017-2018 training year.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
A physical plant inspection was conducted on March 19, 2018. One of two shower stalls in a 2nd floor residential bathroom was observed to have substantial mold growth on some areas. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 705.6 (7) the following will be implemented.
The Facility Manager will hire a contractor to address the mold in the shower stalls at the Gate House for Women by 5/18/2018.
The House Manager Supervisor will monitor the shower stalls for mold following the removal. In the event that the mold reappears, the House Manager Supervisor will contact the Facility Manager to address the issue.
The Clinical Director will oversee this process. |
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
The facility's fire drill logs were reviewed on March 19, 2018, for the period of 3/22/17 - 3/9/18. The facility failed to conduct a fire drill during sleeping hours at least every 6 months. The fire drill logs indicated that a fire drill was conducted during sleeping hours on 6/27/17. The next fire drill conducted during sleeping hours occurred on 3/9/18. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 705.10 the following will be implemented.
The Clinical Director at the Gate House for Women, will ensure that a fire drill is completed every month on rotating shifts.
The House Manager Supervisor will coordinate the fire drills.
The rotation of shifts will include 8-4p.m.- first shift, 4-12a.m. - second shift, and 12-8a.m. -third shift.This rotation will ensure that a third shift fire drill is completed every three months.
This correction has been implemented on 3/20/2018. |
709.32 (c) 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:
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Observations
Administrative documentation was reviewed for the facility's licensing renewal inspection, conducted on March 19, 2018. The facility failed to provide medication policies that included the provision of medication assisted treatment via the approved use of non-narcotic Vivitrol injections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.32 the following will be implemented.
The Program Administrator has updated the medication policy for the Gate House, to include the provision of Vivitrol. This policy was updated on 4/13/2018.
The Program Administrator will ensure that the new medication policy is implemented by 5/1/2018. In addition, the Clinical Director at the Gate House for Women will ensure that the updated policy is followed, by monitoring its implementation.
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