INITIAL COMMENTS
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This report is a result on an on-site licensure renewal inspection conducted on March 11-12, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The 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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709.28 (c) 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.
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Observations
During an onsite annual license renewal inspection conducted on March 13-14, 2019, in one of seven client records reviewed, the project did not obtain an informed and voluntary consent from the client prior to the disclosure of information contained in the client record.For Client #2, an informed and voluntary consent to disclose information was signed by the client, however what was to be disclosed was left blank. That consent form was time stamped by a fax machine on Monday, September 24, 2018 at 20:06:05.Also, for client #2, information was disclosed without a signed and voluntary consent to an attorney on October 5, 2018 indicating client #2 "came to Gate House Behavioral Health Services on September 24, 2018 for a drug and alcohol evaluation". These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28 Confidentiality the following will be implemented:
The Director of Programs has created a standard release of information form to be utilized through out the Gate House. The Clinical Director will ensure that all staff are trained on how to complete the consent to release information in its entirety. The new release form will begin being used on 4/16/2019. The Clinical Director will ensure that all staff are completing all sections of the release, including what information will be disclosed, and staff signature. Clinical Director will begin monitoring this process monthly during regular chart audits beginning 4/22/2019.
The Director of Programs will monitor the progress of this procedure. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
During an onsite annual license renewal inspection conducted on March 13-14, 2019, four of seven client records reviewed did not have a treatment and rehabilitation plan updated at least every 60 days.Client #5 had a treatment and rehabilitation plan last updated on October 24, 2018. An updated treatment and rehabilitation plan should have been completed by December 24, 2018. Client #5 was discharged on January 3, 2019.Client #8 had a treatment and rehabilitation plan last updated on January 9, 2019. An updated treatment and rehabilitation plan should have been completed by March 9, 2019. Client #8 was still an active client at the time of the inspection.Client #13 had a treatment and rehabilitation plan last updated on December 19, 2018. An updated treatment and rehabilitation plan should have been completed by February 19, 2019. Client #13 was still an active client at the time of the inspection.Client #14 had a treatment and rehabilitation plan last updated on January 10, 2019. An updated treatment and rehabilitation plan should have been completed by March 10, 2019. Client #14 was still an active client at the time of the inspection.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.92 Treatment and Rehabilitation Services, the following will be implemented:
The Clinical Director will ensure that each client receiving treatment at Gate House Behavioral Health Services participates in the completion of their updated treatment plan every 60 days. The Program Coordinator will create an excel worksheet that will identify all treatment plan due dates. This form will be updated weekly, and each clinician will have access to this form to assist them in maintaining the standards for timely treatment planning. Clinicians will ensure that the treatment plans are completed prior to the due date to ensure the timeliness of treatment plans. Therefore, clinicians will complete the updated plan with the client as early as the 45th day, and or after, in order not to pass the 60 day due date. This excel worksheet will start being utilized by all clinicians by 4/16/2019. This procedure will begin on 4/16/2019, and will be monitored by the Clinical Director during the monthly chart audits.
The Director of Programs will monitor this procedure. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
During an onsite annual license renewal inspection conducted on March 13-14, 2019, three of seven client records reviewed did not have documentation that counseling services were being provided according to the individual treatment and rehabilitation plan.Client #8's treatment and rehabilitation plan indicated two individual sessions and one group session a month. The client only received one individual session in December 2018 and one individual session in February 2019. There were no documented individual sessions for the month of March as of the time of the inspection. Client #8 was still an active client at the time.Client #13's treatment and rehabilitation plan indicated two individual sessions and one group session a month. The client only received one individual session in January 2019 and one individual session in February 2019. There were no documented individual sessions for the month of March as of the time of the inspection. Client #13 was still an active client at the time.Client #14's treatment and rehabilitation plan indicated two individual sessions and one group session a month. The client only received one individual session in February 2019. Client #14 was still an active client at the time of the inspection. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.92 Treatment and Rehabilitation Services, the following will be implemented:
Since the audit at Gate House Behavioral Health Services a new procedure was implemented on 4/1/2019. Each clinician is now expected to complete the clinical documentation within 24 hours of providing clinical services. The Clinical Director ensures that each clinician completes the individual session documentation note within 24 hours of conducting the session. The Clinical Director will conduct monthly chart reviews to ensure that the procedure is being adhered to.
Director of Programs will monitor the progress of this procedure. |
709.42(h) LICENSURE Expeditious intake process
709.42. Project management.
(h) The intake process shall proceed expeditiously to avoid discouragement and should not exceed a period of 48 hours.
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Observations
During an onsite annual license renewal inspection conducted on March 13-14, 2019, in two of seven Intake Evaluation, and Referral client records reviewed, the intake process exceeded a period of 48 hours.Client #10 and Client #11 both had intakes that exceeded 48 hours. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.42 Expeditious Intake Process the following will be implemented:
Beginning on 4/16/2019, the Clinical Director will ensure that all evaluations conducted at Gate House Behavioral Health Services are completed within 48 hours. The completion of the evaluation will include informing the client of the appropriate recommendations for treatment.
The Director of Programs will monitor this procedure. |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
During an onsite annual license renewal inspection conducted on March 13-14, 2019, three of seven Intake Evaluation, and Referral client records reviewed did not have a completed psychosocial evaluation.The " diagnostic assessment " section on the psychosocial evaluation in clients #10, 11, and 12 was not completed. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.44(a) the following will be implemented:
Beginning 4/16/2019, the Clinical Director will ensure that all clinicians conducting a psychosocial evaluation complete the diagnostic assessment within 48 hours of the appointment date.
The Clinical Director will conduct a monthly chart audit to ensure the completion of the diagnostic assessment beginning 4/17/2019.
The Director of Programs will monitor this procedure. |