INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Gatehouse 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 and a plan of correction is due on March 25, 2010.
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Plan of Correction
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705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on observation during a tour of the physical plant on February 18, 2010 at approximately 3;00 PM, the facility failed to ensure that a minimum of one operable, automatic smoke detector was provided on each floor, including the basement and attic.
The findings were:
A physical plant tour was conducted on February 18 at approximately 3:00 PM. During the physical plant tour it was observed that the facility had a heat detector in the attic, but did not have a smoke detector in the attic, as required by the standards.
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Plan of Correction
Clinical Supervisor spoke with Vector Security and was notified that they do not place smoke detectors in attics due to the drastic change in temperatures. With documentation from Vector, The Gate House for Women will be requesting exception to this standard and continue to use the existing heat detector. |
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 and training records on February 18, 2010 the facility failed to document that all staff were instructed in the use of the fire extinguisher upon employment.
The findings were:
Five personnel records and training records were reviewed on February 18, 2010. Two out of five records reviewed lacked documentation to verify that staff were trained in the use of fire extinguishers, #4 & 5.
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Plan of Correction
Employee #4 & #5 did receive their fire extinguisher training but it was not within the required 7 days.
The Administrative Coordinator who has the Human Resource duties will provide Fire Safety and Emergency Training on the first day of employment. Human Resource duties have been brought in-house during the past year. Administrative Coordinator will ensure compliance. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and training records on February 18, 2010 the facility failed to document that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings were:
Five personnel records and training records were reviewed on February 18, 2010. Two out of five records reviewed lacked documentation to verify that all personnel on all shifts are trained to perform assigned tasks during emergencies, #4 & 5.
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Plan of Correction
Employee #4 & #5 did receive the required emergency training but not within the required 7 days. The training certificate has been updated to read Fire Safety and Emergency Training.
The Administrative Coordinator who has the Human Resource duties will provide Fire Safety and Emergency Training on the first day of employment. Human Resource duties have been brought in-house during the past year. Administrative Coordinator will ensure compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document complete psychosocial evaluations in two of four client records.
The finding includes:
Five client records were reviewed on February 18, 2010. One of the five was only reviewed for documentation related to discharge; therefore the psychosocial evaluation was not reviewed in record #5. Psychosocial evaluations were due to be documented in four client records, specifically client records # 1, 2, 3, and 4.
Client record #1, failed to evaluate the client's composite picture, problems/needs, and negative factors that might inhibit treatment. The evaluation lacked a clinical assessment, exclusively used the client's opinion, and provided minimal detail.
Client record #2, failed to evaluate the client's problems/needs, assets and strengths, negative factors that might inhibit treatment, and the counselor's conclusions and impressions. The evaluation lacked a clinical assessment, exclusively used the client's opinion, and provided minimal detail.
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Plan of Correction
Clinical Supervisor will conduct a training on Psychosocial Assessments and Treatment Plans for all clinical staff to attend. Training will be held on 3/24/10 at The Gate House for Women from 9-11 a.m. To ensure compliance,
the clinical supervisor will review all psychosocial evaluations for a period of three months. If at the end of three months the facility is still out of compliance the clinical supervisor will conduct another training session and continue to review all psychosocial evaluations until compliance is achieved. Once compliance has been achieved, the clinical supervisor will review psychosocial evaluations randomly on a quarterly basis. |