D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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GATE HOUSE - MARIETTA
4940 MARIETTA AVENUE
MARIETTA, PA 17547

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Survey conducted on 02/01/2022

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on February 1, 2022 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-Marietta 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:	Plan of Correction
704.3(d) LICENSURE 24 Hour Coverage 704.3. General requirements for projects. (d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
Observations Based on a review of the facility staff schedules, the facility failed to provide 24-hour staff coverage for the hours of 8 am- 9am on December 12,19, 26 and from 6 am-9 am on December 14, 2021. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 704.3 (d) the following will be implemented: Beginning on 2/23/22, the Residential Program Supervisor will ensure that there is 24 hour staff coverage. The staffing hours will be reflected on the staff schedule and updated as needed. The Clinical Director will monitor this action plan monthly during supervisory meetings.
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.
Observations Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to provide documentation of a written individual training plan for each employee, appropriate to that employee's skill level, and developed with both the employee and the employee's supervisor for employee # 8. Employee # 8 was hired as a support staff on August 10, 2021 and was still in this position at the time of the inspection. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 704.11 (b) (1), the following will be implemented: Beginning on 2/23/22, the Clinical Director will ensure that all newly hired employees develop, review, and sign a written individual training plan with their direct supervisor. In addition, all employees will develop, review, and sign a written individual training plan with their direct supervisor at the beginning of the fiscal year (July). Each individual training plan will be designed to meet the employees skill level. The Director of Programs will monitor the progress of this action plan at the beginning of the fiscal year. The Human Resource Generalist will monitor this action plan for all new employees during the time of hire.
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training 704.11. Staff development program. (c) General training requirements. (1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
Observations Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #6 and #7 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe. Employee #6 was hired as a support staff on April 24, 2019 and was still in this position at the time of the inspection. Employee # 6 was due to have the communicable disease trainings no later than April 24, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection. Employee #7 was hired as a support staff on February 25, 2019 and was still in this position at the time of the inspection. Employee # 7 was due to have the communicable disease trainings no later than February 25, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection. The findings were reviewed with facility staff during the licensing process. This is a repeat citation from the September 10, 2021 annual licensing inspection.	Plan of Correction In an effort to address citation 704.11 (c) (1), the following will be implemented: Beginning on 2/23/22, all newly hired support staff will attend a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training within two years of their hire date. The program assistant will maintain an employee record which indicates the time frames and due dates for all trainings per staff. Notification of training time frames and due dates will be emailed to the staff person's direct supervisor on a quarterly basis. The Clinical Director will monitor the progress of this action plan during monthly supervision.
705.10 (d) (6) LICENSURE Fire safety. 705.10. Fire safety. (d) Fire drills. The residential facility shall: (6) Prepare alternate exit routes to be used during fire drills.
Observations Based on a review of the 2021 facility fire drill log, the facility failed to prepare alternate exit routes to be used during fire drills. Documentation on the fire drill log indicated all exits used during fire drills was through the kitchen door. The findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 705.10 (d) (6), the following will be implemented: Beginning on 2/23/22, the Residential Program Supervisor will ensure that the monthly fire drills are scheduled to include different exits throughout the facility on a rotating basis. The Clinical Director will monitor the progress of this action plan during monthly supervision.
709.32 (c) (1) (i) - (ii) LICENSURE Medication control § 709.32. Medication control. (c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to: (1) Administration of medication, including the documentation of the administration of medication: (i) By individuals permitted to administer by Pennsylvania law. (ii) When self administered by the client.
Observations Based on seven of seven client records reviewed, the facility failed to provide documentation of the administration of medication according to the facility policy and procedure manual. The policy and procedure manual indicates that both the staff and client will document on the medicated administration record whether or not the medication was taken. Client # 1 was admitted on November 15, 2021 and was still active at the time of the inspection. A medication prescribed to be taken one time at 9 pm was not documented on the medication administration record to have been taken one time at 9 pm on the dates of January 19, 24, 25, and 28, 2022. Client # 2 was admitted on December 27, 2021 and was still active at the time of the inspection. A medication prescribed to be taken one film daily was not documented on the medication administration record to have been taken one film daily on the dates of January 22, 2022 and January 25-January 31, 2022. Also, a medication prescribed to be taken one time daily was not documented on the medication administration record to have been taken one time daily on the dates of January 6 and 12, 2022. Client # 3 was admitted on December 20, 2021 and was still active at the time of the inspection. A medication prescribed to be taken three times daily was not documented on the medication administration record to have been taken three times daily. The prescribed medication was given one time on the dates of December 21, 22, 29, 30, 31, 2021 and January 2, 3, 4, 5, 7, 9, 11, 13, and 23, 2022. Two times on the dates of December 23, 24, 25, 26, 27, 28, 2021 and January 1, 6, and 8, 2022. No medication was documented the dates of January 10, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, 30, and 31, 2022. Client # 4 was admitted on January 24, 2022 and was still active at the time of the inspection. A medication prescribed to be taken one time daily at 7 am was not documented on the medication administration record to have been taken one time daily at 7 am on the date of January 27, 2022. Also, A medication prescribed to be taken at one time daily at 9 pm was not documented on the medication administration record to have been taken at 9 pm on the date of January 27, 2022. Client # 5 was admitted on October 14, 2021 and was discharged on January 3, 2022. A medication prescribed to be taken one time daily at 7 am was not documented on the medication administration record to have been taken one time daily at 7 am on the dates of October 19, 20, 26, December 9, 11, 13, 19, 22, 2021 and January 2, 2022. A medication prescribed to be taken at one time daily at 9 pm was not documented on the medication administration record to have been taken at 9 pm on the dates of October 18, 21, December 4, 5, 18, 22, 25, 27, 29, 30, 2021 and January 2, 2022. Another medication prescribed to be taken at one time daily at 9 pm was not documented on the medication administration record to have been taken at 9 pm on the dates of October 18, 21, 31, November 6, 7, 21, 25, December 4, 12, 13, 18, 22, 25, 27, 28, 2021 and January 1, 2, 2022. Another medication prescribed to be taken daily at 7 am was not documented on the medication administration record to have been taken daily at 7 am on the dates of October 19, 20, 26, December 9, 11, 19, 22, 2021 and January 2, 2022. Client # 6 was admitted on December 27, 2021 and was discharged on January 21, 2022. A medication prescribed to be taken one time daily at 7 am was not documented on the medication administration record to have been taken one time daily at 7 am on the date of December 29, 31, 2021 and January 2, 3, 4, 8, 9, 14, 16, 17, 18, 2022. Another medication prescribed to be taken one time daily at 7 am was not documented on the medication administration record to have been taken one time daily at 7 am on the date of December 30, 2021. Another medication prescribed to be taken one time daily at 7 am was not documented on the medication administration record to have been taken one time daily at 7 am on the date of December 28, 20, 30, 31, 2021 and January 1, 2, 3, 4, 5, 18, 2022. A medication prescribed to be taken two times daily at 7 am and 9 pm was not documented on the medication administration record to have been taken at 7 am and 9 pm on the dates of December 29, 2021 and January 4, 8, 9, 16, 18, 19, 2022. Client # 7 was admitted on August 30, 2021 and was discharged on January 20, 2022. A medication prescribed to be taken one time daily at 7 am was not documented on the medication administration record to have been taken one time daily at 7 am on the dates of September 6, 2021 through January 20, 2022. Another medication prescribed to be taken one time daily at 7 am was not documented on the medication administration record to have been taken one time daily at 7 am on the dates of September 20, November 3, 16, 25, December 2, 7, 2021 and January 4, 10, 11, 12, 2022. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In an effort to address citation 709.32 (c) (1), the following will be implemented: Beginning on 2/23/2022, the Clinical Director will ensure that all staff are trained on documenting whether or not the client has taken their medication on the Medication Administration Records. The staff assigned to complete the observation of the administration of medications, will indicate the reason why the client did not take their medication on the Medication Administration Records, and have the client sign off. The Director of Programs will monitor the progress of this action plan during monthly supervisions.