INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 19, 2023 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:
|
Plan of Correction
|
704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close supervision by a trained counselor or clinical supervisor for the first 6 months of employment.Employee #4 was hired on February 7, 2023 and was still employed at the time of the inspection. He had no documentation of direct observation and did not have weekly close supervision.This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 704.9 (c), the following will be implemented:
Beginning on 1/3/2024, the Clinical Supervisor will ensure that weekly close supervision and direct observation is facilitated with all counselor assistants. Counselor Assistants with a Bachelors Degree will receive weekly supervision for 6 months.
The Clinical Director will monitor this action step during monthly supervision with the Clinical Director.
|
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.
|
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 in one out of two applicable records reviewed.Employee #1 was hired as the Project Director on October 2,2017 and was still employed at the time of the inspection. The annual evaluation for 2023 was not signed nor dated.This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 709.26
(b) (3), the following will be
implemented:
Beginning on 1/3/2024, the HR
Generalist will ensure that all annual
evaluations for employees are
signed and dated prior to filing them
in the employees record. In addition,
the HR Generalist will train all
supervisors across the organization
to ensure that the employees annual
evaluation is signed and dated prior
to submitting it to the HR Generalist.
The Executive Director will monitor
the progress of this action step
during monthly supervision with the
HR Generalist. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
Based on a review of outpatient client records, the facility failed to obtain a consent to release information form prior to releasing information in two out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.Client #1 was admitted on September 20, 2023 and was still active at the time of the inspection.Client #6 was admitted on October 20, 2023 and was discharged on November 14, 2023.These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
In an effort to address citation 709.28 (c), the following will be implemented:
Beginning on 1/3/2024, the Program Assistant will ensure that all newly admitted clients sign a consent to release information for their funding source.
The Clinical Director will monitor this action step while completing a monthly chart audit and discuss in monthly supervision with the Program Assistant. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on the review of outpatient client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client records reviewed.Client #6 was admitted on October 20, 2023 and was discharged on November 24, 2023. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
In an effort to address citation 709.33 (a), the following will be implemented:
Beginning on 1/3/2023, all counselors will ensure that any client assigned to their caseload who has been discharged prematurely receive a notice of treatment termination. The Clinical Supervisor will train all counselors on how to complete the treatment termination notice.
The Clinical Director will monitor this action step while completing monthly chart reviews, and discuss with the Clinical Supervisor in monthly supervision. |
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.
|
Observations
Based on a review of outpatient client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of two applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 30, 60 and 90 days following discharge.Client #7 was admitted on September 22, 2023 and was discharged on November 15, 2023. A follow up was due no later than December 15, 2023; however, none was completed.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 709.93 (a) (11), the following will be implemented:
Beginning on 1/3/2024, the Program Assistant will ensure that all clients receive a follow up contact at 30, 60, and 90 days post discharge. The Clinical Supervisor will train the Program Assistant on completing this task.
The Clinical Director will monitor this action step while completing monthly chart reviews, and monthly supervision with the Program Assistant. |