INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, GateHouse Mountville 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 one out of six employee records reviewed.
Employee #1 was promoted to Project Director on December 4, 2024 and was still in the position as of the date of the inspection. There is no plan for her current position.
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
(b) (1) the following procedures will
be implemented:
Beginning 1/8/2025, 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 an 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 |
705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed.
Bedroom #7 bunk bed did not allow for a resident to sit up in the top bed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.5 (b), the following will be implemented:
Beginning 1/8/2025, the Maintenance staff will adjust the top bunk bed in room 7, to ensure that there is enough space for the client to sit up in bed.
The Residential Program Supervisor will ensure that the adjustment remains the same while completing weekly walk throughs of the facility.
The Director of Maintenance will oversee the consistency of this action step when completing facility walk throughs on a quarterly basis. |
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 the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure all employees received the required training in the use of the fire extinguishers upon employment.
Employee #4 was hired on March 6, 2024 for the position of counselor and was still employed at the time of the inspection. He did not have the training until August 31, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (c) (4) the following will be implemented:
Beginning 1/8/2025, the HR Generalist will ensure that all newly hired employees complete the Fire Safety Training within their initial week of employment. Each new staff is assigned the Fire Safety training during orientation, the HR Generalist will follow up to ensure its completion for each new staff person within their initial week of employment.
The Director of Compliance will oversee the completion of this task during monthly management meetings. |
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 the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure all employees received the required training to perform assigned tasks during emergencies.
Employee #4 was hired on March 6, 2024 for the position of counselor and was still employed at the time of the inspection. He did not have the training until August 31, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (d) (3) the following will be implemented:
Beginning 1/8/2025, the HR Generalist will ensure that all newly hired employees complete the Fire Safety Training, which includes Emergency Procedures within their initial week of employment. Each new staff is assigned the Fire Safety training during orientation, the HR Generalist will follow up to ensure its completion for each new staff person within their initial week of employment.
The Director of Compliance will oversee the completion of this task during monthly management meetings.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 December 2023 through November 2024 fire drill logs during the inspection, the facility failed to document the time, the exit route used and the number of persons in the facility at the time of the drill. This information was not documented during the January 13, 2024 drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (d) (4), the following will be implemented:
Beginning 1/8/2025, the Residential Program Supervisor will train all the facility staff on the proper procedures for conducting a fire drill. The training will include the requirement of documenting the time, route, exit, and number of persons included. The Residential Program Supervisor will ensure that each monthly fire drill is documented to include the above mentioned, as well as ensuring that the drills are rotated by shifts.
The Program Director will oversee the outcome of this procedure during monthly supervision. |
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 and signed by the employee. The facility's policy and procedure states that an evaluation will be completed 90 days following a promotion.
Employee #1 was promoted to the Project Director on December 4, 2023 and was still employed at the time of the inspection. A 90-day written performance evaluation was due no later than March 4, 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 procedure will
be implemented:
Beginning 1/8/2025, 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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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in five out of seven client records reviewed.
Client #1 was admitted on September 11, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was developed on September 12, 2024 with no type or frequency identified.
Client #2 was admitted on September 17, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 20, 2024 with no type or frequency identified.
Client #3 was admitted on September 19, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on September 20, 2024 with no frequency identified.
Client #6 was admitted on June 20, 2024 and discharged on August 28, 2024. A comprehensive treatment plan was developed on June 21, 2024 with no frequency identified.
Client #7 was admitted on June 12, 2024 and discharged on September 1, 2024. A comprehensive treatment plan was developed on June 14, 2024 with no frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.52 (a) (2), the following will be implemented:
Beginning 1/8/2025, the Clinical Supervisor will ensure that each clinician completes the type and frequency on each treatment plan. The Clinical Supervisor will train all the clinicians regarding the regulation to record the type and frequency when completing a treatment plan.
The Program Director will oversee the progress of this procedure while meeting with the Clinical Supervisor for monthly supervision, and while completing random chart audits. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven client records reviewed.
Client #1 was admitted on September 11, 2024 and was still active at the time of the inspection. A treatment plan update was developed on November 6, 2024 and the next update was due no later than December 6, 2024; however, none was completed.
Client #2 was admitted on September 17, 2024 and was still active at the time of the inspection. A treatment plan update was developed on November 12, 2024 and the next update was due no later than December 12, 2024; however, none was completed.
Client #7 was admitted on June 12, 2024 and discharged on September 1, 2024. A comprehensive treatment plan was developed on June 14, 2024 and the update was due no later than July 14, 2024; however, it was not completed until August 29, 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 709.52 (b), the following will be implemented:
Beginning 1/9/2025, the Clinical Supervisor will ensure that all treatment plans are completed within the 30 day time frame. The Clinical Supervisor will train all the clinicians on the requirement to ensure treatment plans are completed with the clients input every 30 days from the date of their admission. The Clinical Supervisor will monitor the progress of this action step during weekly clinical meeting.
The Program Director will oversee this action step during monthly supervision with the Clinical Supervisor. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of three records reviewed.
Client #6 was admitted on June 20, 2024 and discharged on August 28, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.53 (a) (10), the following will be implemented:
Beginning 1/9/2025, the Clinical Supervisor will ensure that all client records are completed following discharge, to include the discharge summary. The Clinical Supervisor will train all the clinicians on the requirements of all documentation to include discharge summaries. The clinicians will be given 14 days from the date of the clients discharge to ensure that the clients record is completed and prepared for an audit. The Clinical Supervisor completes a monthly quality inspection of all closed charts from the previous month. The Clinical Supervisor will monitor the implementation of this action step monthly while completing chart audits.
The Program Director will oversee the progress of this action step while meeting with the Clinical Supervisor monthly for supervision. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 two out of three applicable records reviewed. The facility's policy and procedures manual states that follow up must be completed 7, 30 and 90 days following discharge.
Client #6 was admitted on June 20, 2024 and discharged on August 28, 2024. A follow up was due no later than September 4, 2024; however, it was not completed until September 10, 2024.
Client #7 was admitted on June 12, 2024 and was discharged on September 1, 2024. A follow up was due no later than September 8, 2024; however, it was not completed until September 11, 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 709.53 (a) (11), the following will be implemented:
The Program Assistant will complete and document follow up calls for all clients at 7, 30, and 90 days post discharge. The follow-up contact will be documented in the clients record.
The Program Director will monitor this action step by completing random chart audits, and will meeting with the Program Assistant for monthly supervision. |