INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Gate House 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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709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of six client records on September 30, 2020, the project failed to develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the clients right to submit rebuttal data or memoranda to his own records.This information was reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.30 Client Rights, the following will be implemented:
The Clinical Supervisor will ensure that each client is informed of their right to submit a rebuttal or memoranda to their own record. This information will be added to the Client Rights form, and the form will be signed by the client and electronically filed in the clients record. This correction will be implemented by 3/4/2021.
The Clinical Director will monitor this action step during the monthly quality assurance report. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of six client records on September 30, 2020, the project failed to provide documentation of a client orientation to the project which includes a familiarization with the hours of operation in three records reviewed.Client #3 was admitted on April 16, 2020 and discharged on August 13, 2020. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #4 was admitted on April 28, 2020 and discharged on July 5, 2020. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.Client #5 was admitted on March 4, 2020 and was current at the time of the inspection. The project failed to document a client orientation to the project which includes a familiarization with the hours of operation.This information was reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.51 (b) (2) the following will be implemented:
The Clinical Director will update the client orientation manual to include the facilities hours of operation by 3/4/2021. Each client will receive a copy of the facilities orientation manual during the time of admission.
The Directors of Programs will monitor this action step to ensure full compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of six client records on September 30, 2020, the project failed to develop intake procedures which include the documentation of a physical examination in three records reviewed.Client #3 was admitted on April 16, 2020 and discharged on August 13, 2020. The project failed to document a physical examination.Client #4 was admitted on April 28, 2020 and discharged on July 5, 2020. The project failed to document a physical examination.Client #5 was admitted on March 4, 2020 and was current at the time of the inspection. The project failed to document a physical examination.This information was reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.51 (b) (5) Physical Exams, the following will be implemented:
The Intake Supervisor will ensure that each referring facility sends a completed physical examination for the client being referred to Gate House Marietta. The physical examination will be uploaded to the Gate House electronic record keeping database. This action step will be implemented on 3/4/2021. In the event that the client has not had a physical examination within the previous 12 months, the Clinical Director will ensure that the client obtains a physical examination within 7 days of admission. This action step will begin on 3/4/2021.
The Director of Programs will monitor this action step during the monthly supervision with the Intake Supervisor and the Clinical Director. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of six client records on September 30, 2020, the facility failed review and update treatment and rehabilitation plans at least every thirty days in one record reviewed.Client #3 was admitted on April 16, 2020, discharged on August 13, 2020 and did not have an updated treatment plan for August 9, 2020.This information was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.52 (b) Treatment Plan Updates, the following will be implemented:
The Clinical Supervisor will ensure that each clinician completes an updated treatment plan with each client on their case load every thirty days. This action step will begin on 3/4/2021. The Clinical Supervisor will monitor this action step during the completion of the monthly chart review.
The Clinical Director will monitor the progress of this action step during monthly supervision. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. 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
Based on a review of six client records on September 30, 2020, the project failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in two records reviewed.Client # 3 was admitted on April 16, 2020 and discharged on August 13, 2020. The project failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan. Treatment plan dated for May 15, 2020 to June 14, 2020 indicates the following services to be provided:1 Small Group Counseling Session per Week1 Anger Management Counseling Session per week1 Individual Counseling Session per WeekAnger Management Session and Individual Session not provided for the week of May 15, 2020 to May 21, 2020.Anger Management Session not provided for the week of May 22, 2020 to May 28, 2020.Small Group Session and Anger Management Session not provided for the week of May 29, 2020 to June 4, 2020.Treatment plan dated for June15, 2020 to July 10, 2020 indicates the following services to be provided:1 Small Group Counseling Session per Week1 Anger Management Counseling Session per week1 Individual Counseling Session per WeekAnger Management Session not provided for the week of June 15, 2020 to June 21, 2020.Anger Management Session not provided for the week of June 22, 2020 to June 28, 2020.Anger Management Session not provided for the week of June 29, 2020 to July 5, 2020.Treatment plan dated for July 9, 2020 to August 8, 2020 indicates the following services to be provided:1 Small Group Counseling Session per Week1 Anger Management Counseling Session per week1 Individual Counseling Session per Week1 Family Counseling Session per MonthFamily Counseling Session not provided for the month of July 9, 2020 to August 8, 2020.Anger Management Session not provided for the week of July 9, 2020 to July 15, 2020Small Group Session, Anger Management Session, and Individual Session not provided for the week of July 16, 2020 to July 22, 2020.Client # 4 was admitted on April 28, 2020 and discharged on July 5, 2020. The project failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan. Treatment plan dated for April 29, 2020 to May 29, 2020 indicates the following services to be provided:1 Family Counseling Session per MonthFamily Counseling Session not provided for the month of April 29, 2020 to May 29, 2020.Treatment plan dated for May 29, 2020 to June 28, 2020 indicates the following services to be provided:4 Life Skills Sessions per week1 Family Counseling Session per MonthFamily Counseling Session not provided for the month of May 29, 2020 to June 28, 2020.Three Life skills Sessions not provided for the week of May 29, 2020-June 4, 2020.Three Life skills Sessions not provided for the week of June 5, 2020-June 11, 2020.Three Life skills Sessions not provided for the week of June 12, 2020-June 18, 2020.Three Life skills Sessions not provided for the week of June 19, 2020-June 28, 2020.Treatment plan dated for June 28, 2020 to July 28, 2020 indicates the following services to be provided:4 Life Skills Sessions per weekThree Life skills Sessions not provided for the week of June 28, 2020-July 3, 2020.This information was reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.52 (c) the following will be implemented:
The clinicians will ensure that each client receives the services that are listed on the treatment plan. This action step will begin on 3/4/2021. In the event that there are any changes to the services, the change will be recorded on the clients treatment plan.
The Clinical Supervisor will monitor the progress of this action step, during the monthly chart review. |