INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Gate House 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:
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Plan of Correction
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of outpatient client records, the facility failed to document medical histories in two of three outpatient client records.
The findings include:
Three outpatient client records were reviewed for documentation of a medical history on March 27, 2013. Two out of three client records either failed to update a medical history or did not document a medical history at all, specifically records # 1 and 2.
Client #1 was admitted on January 29, 2013. There was a medical history documented for client #1, however it was collected prior to the client's admittance into the outpatient program and had not been updated to reflect the client's current status.
Client #2 was admitted on February 6, 2013. The medical history was due at intake. As of the date of inspection, there was no documentation of a medical history for client #2.
The findings were reviewed with the clinical staff during the exit interview.
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Plan of Correction
To ensure this standard is followed, the clinical supervisor has met with the outpatient counselor. Beginning immediately, upon admission to The Gate House Outpatient Program, the Outpatient Counselor will complete a new medical history, documenting the client's personal medical history, family history, and history of illness and symptoms, with the client if the existing medical history is older than six months. If the medical history was collected within six months of client's admittance into The Gate House Outpatient Program, the Outpatient Counselor will update it to reflect the client's current status. The Clinical Supervisor will monitor this activity for the next six months to ensure that it is being completed and reflects the client's current status. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of outpatient client records, the facility failed to document drug or alcohol histories in two of three outpatient client records.
The findings include:
Three outpatient client records were reviewed for documentation of a drug or alcohol history on March 27, 2013. Two out of three client records either failed to update a drug or alcohol history or did not document a drug or alcohol history at all, specifically records # 1 and 2.
Client #1 was admitted on January 29, 2013. There was a drug or alcohol history documented for client #1, however it was collected prior to the client's admittance into the outpatient program and had not been updated to reflect the client's current status.
Client #2 was admitted on February 6, 2013. The drug or alcohol history was due at intake. As of the date of inspection, there was no documentation of a drug or alcohol history for client #2.
The findings were reviewed with the clinical staff during the exit interview.
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Plan of Correction
To ensure this standard is followed, the clinical supervisor has met with the outpatient counselor. Beginning immediately, upon admission to The Gate House Outpatient Program, the Outpatient Counselor will complete a new drug or alcohol history, documenting the substances most frequently abused, the length and patterns of use, prior treatment episodes, client's perceptions of their effects on his/her social, physical, and mental state, and substance use history within the family, with the client if the existing drug and alcohol history is older than six months. If the drug or alcohol history was collected within six months of client's admittance into The Gate House Outpatient Program, the Outpatient Counselor will update it to reflect the client's current status. The Clinical Supervisor will monitor this activity for the next six months to ensure that it is being completed and reflects the client's current status. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of outpatient client records, the facility failed to document personal histories in two of three outpatient client records.
The findings include:
Three outpatient client records were reviewed for documentation of a personal history on March 27, 2013. Two out of three client records either failed to update a personal history or did not document a personal history, specifically records # 1 and 2.
Client #1 was admitted on January 29, 2013. There was a personal history documented for client #1, however it was collected prior to the client's admittance into the outpatient program and had not been updated to reflect the client's current status.
Client #2 was admitted on February 6, 2013. The personal history was due at intake. As of the date of inspection, there was no documentation of a personal history for client #2.
The findings were reviewed with the clinical staff during the exit interview.
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Plan of Correction
To ensure this standard is followed, the clinical supervisor has met with the outpatient counselor. Beginning immediately, upon admission to The Gate House Outpatient Program, the Outpatient Counselor will complete a new personal history, documenting family, legal, employment/vocational, educational, military, recreational, and sexual data, with the client if the existing personal history is older than six months. If the personal history was collected within six months of client's admittance into The Gate House Outpatient Program, the Outpatient Counselor will update it to reflect the client's current status. The Clinical Supervisor will monitor this activity for the next six months to ensure that it is being completed and reflects the client's current status. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of outpatient client records, the facility failed to document a psychosocial assessment in two of three outpatient client records.
The findings include:
Three outpatient client records were reviewed for documentation of a psychosocial assessment on March 27, 2013. Two out of three client records failed to include a psychosocial assessment, specifically records # 1 and 2.
Client #1 was admitted on January 29, 2013. A psychosocial assessment was due at intake. As of the date of inspection, there was no documentation of a psychosocial evaluation for client #1.
Client #2 was admitted on February 6, 2013. A psychosocial assessment was due at intake. As of the date of inspection, there was no documentation of a psychosocial evaluation for client #2.
The findings were reviewed with the clinical staff during the exit interview.
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Plan of Correction
To ensure this standard is followed, the clinical supervisor has met with the outpatient counselor. Beginning immediately, the Outpatient Counselor will meet with all new admissions to The Gate House Outpatient Program to complete a Psychosocial evaluation that includes: client's presenting problem, needs/problems that cannot be resolved through treatment, client assists and strengths, client support systems, negative factors that might affect treatment, client's preferred coping mechanisms, and conclusions regarding client's appearance, behavior, attitude, and ability to participate in the treatment process. The Clinical Supervisor will monitor this activity for the next six months to ensure that it is being completed. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of outpatient client records, the facility failed to document a preliminary treatment plan in two of three outpatient client records.
The findings include:
Three outpatient client records were reviewed for documentation of a preliminary treatment plan on March 27, 2013. Two out of three client records failed to include documentation of a preliminary treatment plan, specifically records # 1 and 2.
Client #1 was admitted on January 29, 2013. A preliminary treatment plan was due at intake. As of the date of inspection, there was no documentation of a preliminary treatment plan for client #1.
Client #2 was admitted on February 6, 2013. A preliminary treatment plan was due at intake. As of the date of inspection, there was no documentation of a preliminary treatment plan for client #2.
The findings were reviewed with the clinical staff during the exit interview.
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Plan of Correction
To ensure this standard is followed, the clinical supervisor has met with the outpatient counselor. Beginning immediately, upon completion of their psychosocial evaluation, each new client of The Gate House Outpatient will receive a preliminary treatment plan outlining program requirements and client treatment needs, by the Outpatient Counselor. The Clinical Supervisor will monitor this activity for the next six months to ensure that it is being completed |
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 outpatient client records, the facility failed to document a comprehensive treatment plan to include the type and frequency of services.
The findings include:
Three outpatient client records were reviewed for documentation of a comprehensive treatment plan that included the type and frequency of treatment services on March 27, 2013. Three out of three client records failed to include documentation of a comprehensive treatment plan that included the type and frequency of treatment services, specifically records # 1, 2, and 3.
Client #1 was admitted on January 29, 2013. The comprehensive treatment plan was documented on February 26, 2013; however it did not include the type and frequency of treatment services for client #1.
Client #2 was admitted on February 6, 2013. The comprehensive treatment plan was documented on March 4, 2013; however it did not include the type and frequency of treatment services for client #2.
Client #3 was admitted on February 3, 2013 and discharged on February 20, 2013. The comprehensive treatment plan was documented on February 14, 2013; however it did not include the type and frequency of treatment services for client #3.
The findings were reviewed with the clinical staff during the exit interview.
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Plan of Correction
To ensure this standard is followed, the clinical supervisor has met with the outpatient counselor. Beginning immediately, each client of The Gate House Outpatient has a comprehensive treatment plan that will include the specific type and frequency of treatment and rehabilitation services to be provided. The Outpatient Counselor will include this information on all treatment plans, and the Clinical Supervisor will monitor this activity for the next six months to ensure that is being completed. |