INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in three out of five employee records reviewed.
Employee #1 was hired on October 2, 2017 and was promoted to Project Director on December 4, 2023 and was still in the position as of the date of the inspection. There is no plan for her current position.
Employee #2 was hired on August 8, 2022 and was promoted to Facility Director on December 4, 2023 and was still in the position as of the date of the inspection. There is no plan for his current position.
Employee #4 was hired on April 22, 2024 as a counselor and was still in the position as of the date of the inspection. There is no training plan.
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 704.11 (b) (1) the following will be implemented:
Beginning 12/27/2024, the HR Generalist will ensure that each employee who is due for an annual evaluation also complete an "Annual Training Plan" with their immediate supervisor. The HR Generalist will notify each supervisor of this procedure and ensure its completion.
The direct supervisors will ensure that the staff they supervise complete and annual "Training Needs Assessment" and that the "Annual Training Plan" is completed with the employee during the time that the "Annual Evaluation" is due (hire date).
The HR Generalist will oversee the completion of this procedure when receiving the staff's "Annual Evaluations". She will ensure that each supervisor is submitting the "Annual Eval", Annual Training Needs Assessment", and "Annual Training Plan". |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #4 was hired as a counselor on February 7, 2023 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2023 through June 30, 2024. Employee # 4's record only documented 17.5 hours of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 704.11 (f) (2), the following will be implemented:
Beginning 12/27/2024, the Clinical Supervisor will ensure that all clinicians register and attend 25 hours of training throughout the fiscal year (July - June).
The Program Director will oversee the completion of this procedure while conducting monthly supervision with the Clinical Supervisor. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to complete an annual written individual staff performance evaluation, a copy of which shall be reviewed ad signed by the employee. The facility's policy and procedures manual states that an evaluation will be completed 90 days following a promotion.
Employee #1 was promoted to Project Director on December 5, 2023 and was still employed at the time of the inspection. A 90 day written performance evaluation was due no later than March 5, 2024; however, none was completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.26 (b) (3), the following will be implemented:
Beginning on 12/27/2024, the HR Generalist will ensure that each employee receives a 90 day evaluation following their date of hire, or 90 days following a promotion.
All supervisors are responsible to complete a 90 day evaluation with the staff they oversee. The 90 day evaluations are submitted to the HR Generalist following the completion of the documentation.
The Director of Compliance will oversee the completion of this procedure during quarterly meeting with the HR Generalist
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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 a review of outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of seven records reviewed.
Client #1 was admitted on August 29, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on August 29, 2024 and an update was due no later than October 29, 2024; however, it was not completed until December 13, 2024.
Client #4 was admitted on March 28, 2024 and was still active at the time of the inspection. A treatment plan update was completed on June 20, 2024 and an update was due no later than August 20, 2024; however, it was not completed until August 30, 2024.
Client #5 was admitted on February 7, 2024 and was discharged on July 1, 2024. A comprehensive treatment plan was completed on February 7, 2024 and the next update was due no later than April 7, 2024; however, it was not completed until May 22, 2024.
Client #7 was admitted on April 18, 2024 and was discharged on August 23, 2024. A comprehensive treatment plan was completed on April 18, 2024 and an update was due no later than June 18, 2024; however, it was not completed until August 7, 2024.
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 (b), the following will be implemented:
Beginning on 12/27/2024, the Clinical Supervisor will ensure that each clinician completes the updated treatment plans with their assigned clients within the 6o day period. Clinical Supervisor will ensure that each clinician understands that the treatment plan updates must be completed within 60 days of the previous treatment plan.
The Program Director will monitor the progress of this procedure during monthly supervision with the Clinical Supervisor, and completing random chart reviews. |
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 document follow up information within guidelines established by the facility's policy and procedures manual in three out of three applicable records reviewed. The facility's policy and procedures manual states that the follow up must be completed at 7, 30, and 90 days following discharge.
Client #5 was admitted on February 7, 2024 and discharged on July 1, 2024. A follow up was due on July 8, 2024; however, none was completed.
Client #6 was admitted on March 19, 2024 and discharged on July 5, 2024. A follow up was due no later than July 12, 2024; however, it was not completed until July 31, 2024.
Client #7 was admitted on April 18, 2024 and was discharged on August 23, 2024. A follow up was due no later than August 30, 2024; however, it was not completed until October 15, 2024.
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) (11), the following will be implemented:
Beginning 12/27/2024, the Program Coordinator will ensure that follow up contacts are made for each client at the following intervals 7, 30, and 90 days post discharge. The Program Coordinator will document the client contact in the clients record.
The Program Director will oversee the progress of this procedure during monthly supervision, and random chart audits. |