INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 28, 2023 through March 1, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher 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 ensure staff were instructed in the use of the fire extinguisher upon staff employment in one of three personnel records reviewed. Employee #3 was hired as a counselor on January 19, 2022. The fire extinguisher training documented in the record was provided to the employee on February 24, 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.23(c)(4), the following will be implemented:
Beginning on 3/13/2023, the Human Resource Generalist will ensure that all new hires are instructed in the use of a fire extinguisher during the first date of employment.
The Executive Director will monitor the progress of this action step during monthly supervision. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of three personnel records reviewed. Employee #3 was hired as a counselor on January 19, 2022. Per the facility's policy and procedure manual, the emergency preparedness training was to be completed on the date of hire; however, the emergency preparedness training documented in the record was provided to the employee on February 24, 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.28(d)(3), the following will be implemented:
Beginning on 3/13/2023, the Human Resource Generalist will ensure that all new hires complete the emergency preparedness training on the initial date of hire.
The Executive Director will monitor this action step during monthly supervision. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the March 2022 through February 2023 fire drill logs, the facility failed to document which exit route was used on every fire drill log completed during the reviewed period, with the exception of April 2022.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.28(d)(4), the following will be implemented:
Beginning on 3/13/23, the Program Coordinator will ensure that the staff and clients utilize different exits during a fire drill. In addition, the Program Coordinator will document the exit that was utilized at each fire drill evacuation.
The Director of Programs will monitor the progress of this action step during monthly supervision. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of eighteen client records reviewed. Client #3 was admitted on December 16, 2022 and was discharged on December 16, 2022. A release of information form to a funding source was signed and dated by the client on December 16, 2022; however, the form did not include the specific information to be disclosed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28(c)(2), the following will be implemented:
Beginning on 3/13/23, the Program Coordinator will ensure that each release of information form is completed in its entirety, including the specific information to be disclosed.
The Director of Programs will monitor the progress of this action step, during monthly supervision. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in three of eighteen client records reviewed. Client #2 was admitted on December 15, 2022 and was discharged on December 15, 2022. A release of information form to a funding source was signed and dated by the client on December 15, 2022; however, the form did not include the purpose of the disclosure. Client #3 was admitted on December 16, 2022 and was discharged on December 16, 2022. A release of information form to a government agency was signed and dated by the client on December 16, 2022; however, the form did not include the purpose of the disclosure. Client #10 was admitted on January 10, 2023 and was active at the time of inspection. A release of information form to a funding source was signed and dated by the client on December 30, 2022; however, the form did not include the purpose of the disclosure. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28(c)(3), the following will be implemented:
Beginning on 3/14/23, the staff at GateHouse Behavioral Health Services will ensure that each client's release of information is completed in its entirety, including the purpose of the disclosure.
In addition, the Program Coordinator will complete a new release of information that includes the purpose of disclosure to the funding source during the next scheduled appointment with client #10.
The Clinical Supervisor will monitor the progress of this action step during the completion of monthly chart audits. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in two of four applicable client records reviewed.Client #15 was admitted into the partial hospitalization activity on December 23, 2021 and discharged on February 23, 2022. There was no follow-up information documented in the record as of the date of the inspection.Client #18 was admitted into the partial hospitalization activity on May 17, 2022 and discharged on July 13, 2022. There was no follow-up information documented in the record as of the date of the inspection.This is a repeat citation from the March 31, 2021 and February 2, 2022 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.83(a)(11), the following will be implemented:
Beginning 3/13/23, the Clinical Supervisor will train the Program Coordinator in the completion of follow up contacts. This training will include the organizations policy to complete follow up contacts following a clients discharge at 30, 60, and 90 days. The completion of this training will be documented.
The Director of Programs will monitor the progress of this action step during monthly supervision. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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 type and frequency of treatment services being provided to the client on individual treatment and rehabilitation plans in three of six applicable client records reviewed. Client #11 was admitted into the outpatient activity on November 15, 2022 and was discharged on February 1, 2023. The individual treatment plan, completed December 12, 2022, did not include the type or frequency of treatment and rehabilitation services to be provided to the client. Client #12 was admitted into the outpatient activity on March 24, 2022 and was discharged on July 7, 2022. The individual treatment plan, completed May 12, 2022, did not include the type or frequency of treatment and rehabilitation services to be provided to the client. Client #13 was admitted into the outpatient activity on June 16, 2022 and was discharged on November 4, 2022. The individual treatment plan, completed July 12, 2022, did not include the type or frequency of treatment and rehabilitation services to be provided to the client. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.92(a)(2), the following will be implemented:
Beginning on 3/13/23, each clinician completing a treatment plan with the input of the client, will ensure that the type and frequency of treatment is documented on the treatment plan.
The Clinical Supervisor will monitor the progress of this action step during the completion of monthly chart audits. |
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
Based on the review of client records, the project failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in one of two applicable client records reviewed.Client #13 was admitted into the outpatient activity on June 16, 2022 and was discharged on November 4, 2022. A treatment plan update was completed on August 25, 2022 and the next update was due no later than October 25, 2022; however, the update was not completed prior to discharge.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.92(b) the following will be implemented:
Beginning 3/13/23, each clinician will ensure that each client assigned to their case load has an reviewed and updated treatment plan every 60 days. In addition, the clinician is responsible to ensure the documentation of all treatment plans.
The Clinical Supervisor will monitor this progress during the completion of the monthly chart reviews. |
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
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in one of three applicable client records reviewed.Client #9 was admitted into the outpatient activity on January 17, 2023 and was active at the time of the inspection. The individual treatment plan, dated February 9, 2023, indicated the client was to receive two individual counseling sessions and one group counseling session per week. The client's record of service and progress notes indicated that the client had received no individual sessions during the week of February 12, 2023 through February 18, 2023. Additionally, during the week of February 19, 2023 through February 25, 2023, there was only one individual counseling session scheduled, which was on February 23, 2023.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.92(c) the following will be implemented:
Beginning on 3/13/23 each clinician will ensure that each client receives the clinical services indicated on the client's completed treatment plan. Each service received will be documented on a DAP note or group note. In the event that the client does not attend the designated service, the clients absence will be documented, and the clinician or program coordinator will contact the client to reschedule the missed appointment.
The Clinical Supervisor will monitor the progress of this action step during the completion of the monthly chart audit.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in two of three applicable client records reviewed.Client #12 was admitted into the outpatient activity on March 24, 2022 and discharged on July 7, 2022. There was follow-up information documented in the record that was dated June 16, 2022, which was prior to the client's discharge.Client #13 was admitted into the outpatient activity on June 16, 2022 and discharged on November 4, 2022. There was follow-up information documented in the record that was dated September 6, 2022, which was prior to the client's discharge.This is a repeat citation from the February 21, 2020, March 31, 2021, and February 2, 2022 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.93(a), the following will be implemented:
Beginning 3/13/23, the Clinical Supervisor will train the Program Coordinator in the completion of follow up contacts. This training will include the organizations policy to complete follow up contacts following a clients discharge at 30, 60, and 90 days. The completion of this training will be documented.
The Director of Programs will monitor the progress of this action step during monthly supervision. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for not documenting follow up information in the client record in the outpatient activity were submitted and approved by the Department for the February 21, 2020, March 31, 2021, and February 2, 2022 annual licensing inspections. Not documenting follow up information in the client record in the outpatient activity was again found to be a deficiency in the February 28, 2023 licensing inspection.Plans of correction for not documenting follow up information in the client record in the partial hospitalization activity were submitted and approved by the Department for the March 31, 2021 and February 2, 2022 annual licensing inspections. Not documenting follow up information in the client record in the partial hospitalization activity was again found to be a deficiency in the February 28, 2023 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.17(a)(3), the following will be implemented:
Beginning on 3/13/23, the Clinical Supervisor will document and train the Program Coordinator on the completion of follow up contacts. This training will include the organizations policy to conduct follow up contacts at 30,60, and 90 days post discharge of all clients. The Program Coordinator will complete and document all follow up contacts at 30, 60, and 90 days post discharge for all clients.
The Director of Programs will monitor this action step during bi-weekly meetings with the Clinical Supervisor and Program Coordinator.
In addition, the Director of Programs will ensure that each Clinical Director adheres to the DDAP approved plan of corrections from this year, and the last two years. The Director of Programs will review and monitor this step during monthly Director meetings. |
709.44(b)(4) LICENSURE Follow-up Information
709.44. Client records.
(b) If applicable, the project shall also include the following items in the client record:
(4) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in one of three applicable client records reviewed.Client #4 was admitted to the intake, evaluation, and referral activity on November 15, 2022 and discharged on November 23, 2022. There was no follow-up information documented in the record as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.44(b)(4) the following will be implemented:
Beginning on 3/13/23 the clinicians and or case managers completing a clients intake, evaluation, and referral will complete a follow up contact with the client within 7 days, if and when the client has been referred to an external provider.
The Clinical Supervisor will monitor the progress of this action step during monthly chart reviews. |