INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26, 2018, by staff from the Division of Drug and Alcohol 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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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of facility records conducted during the on-site inspection, and based on staff interviews conducted during the on-site inspection, the facility failed to acquire written documentation signed by clients that it notified the intake, evaluation and referral clients of their rights. The records for client #s 8, 9, 10, 11, 12, 13 and 14, did not have documentation that clients were notified of their rights. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
As of March 28th 2018, the clinical staff at the GHBHS, were given an updated consent to treatment, created by the Program Administrator. This specific form also includes language which illustrates the acknowledgement of client rights.
Beginning on the 28th of March, the clinical staff assigned to complete evaluations at the GHBHS will utilize the updated form, and ensure that each client is given a copy of the clients rights, and each client will be required to initial the form indicating the receipt of such form.
The lead counselor at GHBHS will ensure that the new form is utilized, and that each client receives a copy of the client rights, along with the clients initials. This action step will be monitored monthly. |
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 facility records conducted during the on-site inspection, the facility failed to document the frequency of services on client individualized treatment plans in 2 of 6 applicable client records reviewed. Client #1 was admitted for treatment on 11/22/2017, and was an active client at the time of the onsite inspection. The client's individualized treatment plan dated 12/18/2017, did not include the frequency of counseling. Client # 2 was admitted for treatment on 12/18/2017, and was an active client at the time of the inspection. The client's individualized treatment plan was dated 01/24/2018, did not include the frequency of counseling. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
In an effort to address 709.92, all treatment plans will include the frequency and type of service on each treatment plan.
During the staff meeting at GHBHS, on 3/28/18, the lead counselor and the program administrator informed all the clinicians of the need to include the type and frequency of services on all treatment plans.
Beginning on 3/29/2018, the lead counselor at the GHBHS will monitor each treatment plan to ensure its accuracy. The lead counselor will monitor this update weekly, as she is required to sign off on each treatment plan. |
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 facility records conducted during the on-site inspection, the facility failed to document treatment plan updates at least once every 60 days in 2 of 5 applicable client records. Client # 1 was admitted for treatment on 11/07/2017, and was an active client at the time of the on-site inspection. The client's individualized treatment plan was dated 11/18/2018, but there was no documented treatment plan update at the time of the on-site inspection. Client #3 was admitted for treatment on 08/15/2017, and discharged on 01/05/2018. The client's individualized treatment plan was dated 09/12/2017, but the client's treatment plan was not updated until 11/21/2017. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
In an effort to address deficiency 709.92, each clinical staff member at the GHBHS will complete the treatment plan update during its allotted time frame.
On 3/28/2018, the lead counselor and program administrator conducted a staff meeting with all the clinical staff members at GHBHS. During this staff meeting, the clinicians were informed of the requirement of completing treatment plan updates every sixty days.
The lead counselor at GHBHS will ensure that each treatment plan update is completed every sixty days, beginning 3/29/2018.
The lead counselor has created an excel worksheet which includes the due dates for clinical documentation, this form will be updated weekly, and each clinician will be given a copy.
The lead counselor will utilize this form to assist in the monitoring of due dates for treatment plan updates. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on a review of facility records conducted during the on-site inspection, and based on staff interviews conducted during the on-site inspection, the facility failed to show that it completed all of the required documentation under client management. The records for client #s 8, 9, 10, 11, 12, 13 and 14 did not have documentation of signed consents for treatment. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
In an effort to address deficiency 709.43, the program administrator for GHBHS, has created an updated consent to treatment. This updated form will be utilized during all evaluations.
On 3/28/2018, the program administrator and the lead counselor conducted a staff meeting that included all clinicians at the GHBHS. During this meeting, the lead counselor reviewed the updated consent to treatment with the clinicians. Beginning 3/29/18, each clinician who completes an evaluation at the GHBHS, will utilize the updated consent to treatment, they will ensure all required signatures are completed.
The lead counselor at GHBHS, will monitor this action step monthly during her chart review. This monitoring will begin on 4/2/2018. |