INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2020 through February 21, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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 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.
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Observations
Based on an annual licensing renewal inspection conducted on February 19, 2020 through February 21, 2020, the project failed to document written acknowledgement by clients that they have been notified of their rights in five out of fourteen records reviewed.Client #1 was admitted on February 19, 2019 and was discharged on June 13, 2019. There was no documentation in the client's record that the client had been notified of their right. Client #2 was admitted on February 27, 2019 and was discharged on August 21, 2019. There was no documentation in the client's record that the client had been notified of their right. Client #3 was admitted on March 20, 2019 and was discharged on August 26, 2019. There was no documentation in the client's record that the client had been notified of their right. Client #4 was admitted on April 25, 2019 and was discharged on November 20, 2019. There was no documentation in the client's record that the client had been notified of their right. Client #5 was admitted on June 13, 2019 and was an active client at the time of the inspection. There was no documentation in the client's record that the client had been notified of their right. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.30 the following will be implemented.
Starting on 3/9/2020 the Clinical Supervisor will ensure that each client signs the form titled, "Client Rights" during the time of admission.
The Program Coordinator is responsible to review the clients rights with each new client during the time of their intake appointment. The Program Coordinator will review the client rights with the client and have them sign the form, which will serve as acknowledgement that they received it. Once the form is signed, a copy will be offered to the client, and the original will be filed in the clients record.
The Director of Programs created a new Client Rights form in July of 2019. Therefore, any new client that was admitted after July of 2019 has signed the new Client Rights form, and it is filed in their chart. A chart review will be conducted by the Program Coordinator and Clinical Supervisor the week of 3/9/2020 to confirm that all existing clients have signed a Client Rights form.
The Clinical Supervisor will monitor this task monthly to ensure its completion. |
709.32 (c) (2) 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:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on an annual licensing renewal inspection conducted on February 19, 2020 through February 21, 2020, the project failed to follow and implement their written policy and procedures regarding all medications used by clients, specifically with regards to drug storage.Per the project's written medication control policy and procedure, "Gate House Behavioral Health Services does not administer or store any other medications outside of Vivitrol." However, during the onsite licensing renewal inspection, it was observed by Department staff that the facility was storing a client's prescribed Buprenorphine in a staff member's desk.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.32 the following procedure will be implemented.
This citation is directly related to the storage of medication that belongs to the clients who reside at the Gate House Transitional Living houses, that are not yet licensed facilities. Beginning 3/6/2020, Gate House Behavioral Health Services will no longer store any medications outside of Vivitrol, which is noted in Policy 709.32.
The Director of Support Services will implement a policy for the handling of medications for clients who reside at the Gate House Transitional Living Houses, which will address the storage of medications for GTL residents.
The Executive Director will monitor this procedure beginning 3/6/2020. |
709.82(d) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
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Observations
Based on an annual licensing renewal inspection conducted on February 19, 2020 through February 21, 2020, the project failed to document that individual counseling sessions and group counseling sessions were provided to a client on a regular and scheduled basis in four out of seven records reviewed.Client #10 was admitted on December 3, 2019 and was a current client at the time of the inspection. Per regulation, the client is to receive a minimum of two individual counseling sessions a week. There was no documentation in the client's record indicating that client was provided the two individual counseling sessions required for the week of February 2, 2020 through February 8, 2020 and one of the two individual counseling session required for the week of February 9, 2020 through February 15, 2020.Client #11 was admitted on December 5, 2019 and was discharged on January 8, 2020. Per regulation, the client was to receive a minimum of two individual counseling sessions a week and two group sessions a week. There was no documentation in the client's record indicating that client was provided the two individual counseling sessions required for the weeks of December 15, 2019 through December 21, 2019 and December 29, 2019 through January 3, 2020. Additionally, there was no documentation in the client's record indicating that client was provided the one of the two individual counseling sessions required and one of the two group counseling sessions required for the week of December 8, 2019 through December 14, 2019. Client #13 was admitted on January 16, 2020 and was a current client at the time of the inspection. Per regulation, the client is to receive a minimum of two individual counseling sessions a week. There was no documentation in the client's record indicating that client was provided the one of the two individual counseling sessions required for the week of January 26, 2020 through February 1, 2020.Client #14 was admitted on February 5, 2020 and was a current client at the time of the inspection. Per regulation, the client is to receive a minimum of two individual counseling sessions a week. There was no documentation in the client's record indicating that client was provided the two individual counseling sessions required and the two group counseling sessions required for the week of for the week of February 9, 2020 through February 15, 2020.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.82 the following will be implemented:
Beginning 3/6/2020 the Clinical Supervisor will ensure that all clients receive two individual sessions and four group sessions per week as stated in Policy 709.82. In the event that the client does not attend the scheduled session or group, the clinician responsible for the service, will document the clients absence for the scheduled appointment and file it in the clients record. In addition, if the client attends the appointment, the clinician responsible for the service will document the service and file it in the clients record.
The Clinical Supervisor will monitor the implementation of this process monthly during chart reviews.
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on an annual licensing renewal inspection conducted on February 19, 2020 through February 21, 2020, the project failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in four out of 7 client records reviewed. Client #1 was admitted on February 19, 2019 and was discharged on June 13, 2019. Treatment plans dated February 19, 2019 and May 16, 2019 indicated that the client was to receive two individual counseling session per month and one group counseling session per week. The record of service and progress notes indicated that the client received a total of one individual counseling sessions for the month of April and a total of three group counseling sessions for the month of May. There was no documentation of client no shows or cancellations during those time periods.Client #3 was admitted on March 20, 2019 and discharged on August 26, 2019. Treatment plans dated March 20, 2019, April 17, 2019 and July 10, 2019 indicated that the client was to receive two individual counseling session per month and one group counseling session per week. The record of service and progress notes indicated that the client received a total of one individual counseling session for the month of May and no group counseling sessions for the months of June, July and August. There was no documentation of client no shows or cancellations during those time periods.Client #5 was admitted on June 13, 2019 and was an active client at the time of the inspection. Treatment plans dated June 13, 2019, July 2, 2019, August 30, 2019 and October 25, 2019 indicate that the client was to receive one group counseling session per week. The record of service and progress notes indicated that the client received a total of two group counseling sessions for the months of October and November, one group counseling session for the month of August and no group counseling sessions for the month of September. There was no documentation of client no shows or cancellations during those time periods.Client #7 was admitted on November 4, 2019 and was a current client at the time of the inspection. Treatment plans dated November 4, 2019 and January 14, 2020 indicate that the client is to receive two individual counseling sessions per month and one group counseling session per week. The record of service and progress notes indicated that the client did not receive individual counseling sessions for the month of November and December and a total of two group counseling sessions for the month of December. There was no documentation of client no shows or cancellations during those time periods.This is a repeat citation from last year's licensure renewal inspection. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.92 the following will be implemented:
Beginning 3/6/2020 the Clinical Supervisor will ensure that all clients receive the services that are indicated on the clients treatment plan. In the event that the client does not attend the scheduled session or group, the clinician responsible for the service, will document the clients absence for the scheduled appointment and file it in the clients record. In addition, if the client attends the appointment, the clinician responsible for the service will document the service and file it in the clients record.
The Clinical Supervisor will monitor the implementation of this process monthly during chart reviews. |
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.
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Observations
Based on an annual licensing renewal inspection conducted on February 19, 2020 through February 21, 2020, the project failed to ensure that there was a complete client record on individuals that includes follow-up information.Client #2 was admitted on February 27, 2019 and was discharged August 21, 2019. The facility failed to document post discharge follow-up information in the client's record.Client #3 was admitted on March 20, 2019 and discharged on August 26, 2019. The facility failed to document post discharge follow-up information in the client's record.Client #4 was admitted on April 25, 2019 and was discharged on November 20, 2019. The facility failed to document post discharge follow-up information in the client's record.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.93 (11), the following procedure will be implemented:
The Clinical Supervisor will ensure that all clients receiving services at Gate House Behavioral Health Services receive a post follow up call at the completion of services. If the client is transferred to a higher level of care the assigned clinician will make contact within 7 days and document the outcome. All other follow up contacts will be completed at 30, 60, and 90 days post discharge, these contacts will be conducted by the Case Manager and/or the Program Coordinator. The outcome of each follow up contact will be documented and filed in the clients record.
This procedure will be implemented by 3/6/2020 and the Clinical Director will monitor the progress monthly during chart reviews. |