INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 2015 and February 4, 2015 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to ensure the facility grounds were in safe and free of hazards.
The findings include:
The physical plant inspection occurred on 1/29/2015. There was a 1' x 1' layer of ice in the middle of the sidewalk egress route directly outside of the exit door of the first floor stairwell by Room 3. This layer of ice presented a fall hazard.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure the grounds are safe and free of hazards. During inclement weather, the House Manager will be responsible to walk the grounds to identify potential snow or ice buildup. She will alert the Maintenance Coordinator so that he can add additional salt to sidewalks and exit zones. The Program Director will oversee this process and ensure that the grounds are safe for clients and staff. The facility corrected this issue immediately, and has been in compliance of the protocol for this standard since February 9, 2015. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to document fire extinguisher training for staff upon employment in three of three personnel records reviewed.
The findings include:
Three personnel records requiring the documentation of fire extinguisher training were reviewed during the renewal inspection on 2/4/2015. The facility failed to document the completion of fire extinguisher training upon employment in personnel records # 1, 2 and 3.
Employee # 1 was hired on 7/11/2014 as a program coordinator. Employee # 1 completed the fire extinguisher training on 7/23/2014.
Employee # 2 was hired on 8/14/2014 as a recovery specialist. Employee # 2 completed the fire extinguisher training on 8/23/2014.
Employee # 3 was hired on 9/30/2014 as a recovery specialist. Employee # 3 completed the fire extinguisher training on 10/14/2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will document training for staff in fire safety and the use of fire extinguishers upon hire. New staff members will be trained by the Administrative Coordinator using appropriate training materials during the new staff member's orientation, which occurs on their first shift at the facility or before. The Administrative Coordinator will instruct the new staff member on how to complete a training evaluation related to the fire safety training, which will then be included in the employee file. The Administrative Coordinator will also include this requirement on the staff orientation checklist, and ensure that it is being completed immediately upon hire. In future, contract employees will follow the same standard as new staff members. All staff members at the facility have received fire safety and fire extinguisher use training as of 2/10/15. The facility will be in compliance with this standard with all new staff members and contracted employees hired on or after March 2, 2015. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan in seven of seven client records reviewed.
The findings include:
Seven client records requiring documentation a preliminary treatment plan were reviewed during the renewal inspection on 1/29/2015. A preliminary treatment plan was not documented in client records # 1, 2, 3, 4, 5, 6 and 7.
Client # 1 was admitted to treatment on 5/9/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 2 was admitted to treatment on 5/15/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 3 was admitted to treatment on 6/10/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 4 was admitted to treatment on 6/10/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 5 was admitted to treatment on 10/14/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 6 was admitted to treatment on 10/30/2014. A preliminary treatment plan was not completed upon admission for the client.
Client # 7 was admitted to treatment on 11/7/2014. A preliminary treatment plan was not completed upon admission for the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will document a preliminary treatment plan for each client on their date of admission. The Lead Counselor will develop and train all staff on the preliminary treatment plan, to include basic functions of the facility and orientation treatment work. It will be included in the intake paperwork, and The Program Coordinator will be responsible for administering this treatment plan. The clinical staff will continue to develop a comprehensive treatment plan with clients within current policy time frames. The Lead Counselor checked and confirmed that all current clients have a comprehensive treatment plan. She will include a check for the preliminary treatment plan during weekly supervision for a period of 3 months to ensure they are being completed. The facility will be in compliance of this standard beginning with all admissions on or after March 9, 2015. |
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 client records, the facility failed to document the frequency of treatment services on the individual treatment and rehabilitation plan in seven of seven client records reviewed.
The findings include:
Seven client records requiring documentation of the type and frequency of treatment services on the individual treatment and rehabilitation plans were reviewed during the renewal inspection on 1/29/2015. The individual treatment and rehabilitation plans contained in client records # 1, 2, 3, 4, 5, 6, and 7 did not include the type and frequency of treatment services.
Client # 1 was admitted to treatment on 5/9/2014. The client's individual treatment and rehabilitation plans dated 6/11/2014 and 7/10/2014 did not specify the type and frequency of individual and group counseling therapy.
Client # 2 was admitted to treatment on 5/15/2014. The client's individual treatment and rehabilitation plans dated 6/13/2014 and 7/11/2014 did not specify the type and frequency of individual and group counseling therapy.
Client # 3 was admitted to treatment on 6/10/2014. The client's individual treatment and rehabilitation plans dated 7/10/2014 and 8/8/2014 did not specify the type and frequency of individual and group counseling therapy.
Client # 4 was admitted to treatment on 6/10/2014. The client's individual treatment and rehabilitation plans dated 7/11/2014, 8/8/2014 and 9/5/2014 did not specify the type and frequency of individual and group counseling therapy.
Client # 5 was admitted to treatment on 10/14/2014. The client's individual treatment and rehabilitation plans dated 11/14/2014 and 12/12/2014 did not specify the type and frequency of individual and group counseling therapy.
Client # 6 was admitted to treatment on 10/30/2014. The client's individual treatment and rehabilitation plans dated 11/28/2014, 12/28/2014 and 1/27/2015 did not specify the type and frequency of individual and group counseling therapy.
Client # 7 was admitted to treatment on 11/7/2014. The client's individual treatment and rehabilitation plans dated 12/11/2014 and 1/10/2015 did not specify the type and frequency of individual and group counseling therapy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will begin to document type and frequency of individual and group counseling sessions on all treatment plans. The Lead Counselor will train all clinical staff on the need to continue to document the type and frequency on not only the first comprehensive treatment plan, but also on all subsequent treatment plans. The Lead Counselor will include a check for the type and frequency on treatment plans during weekly supervision for a period of 3 months to ensure they are being completed. The facility will be in compliance of this standard beginning with all treatment plans, including those of clients who were audited, developed on or after March 2, 2015. |