INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection. The physical plant inspection was conducted on August 13, 2026, and the client record review was conducted on August 14, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gratitude House 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
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on the review of client records, the facility failed to follow their policy to contact a client ' s emergency contact within twelve hours of leaving against medical advice in one out of one applicable record reviewed.
Client #6 was admitted on October 24, 2025, and left against medical advice on February 26, 2026. There was no documentation that the emergency contact was notified.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
ED reviewed policy and reeducated clinical staff on contacting emergency contacts within 12 hours of AFA/behavioral discharges during clinical team meeting on 8/25/26. Clinical supervisor will monitor that this is complete during monthly chart audits. |
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information for clients within seven days of discharge, per facility policy, in two out of four applicable records reviewed.
Client #4 was admitted on November 25, 2025, and discharged on January 14, 2026. A follow up was due no later than January 21, 2026; however, it was not completed until January 30, 2026.
Client #6 was admitted on October 24, 2025, and discharged on February 26, 2026. A follow up was due no later than March 5, 2026; however, it was not completed until March 10, 2026.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
ED reviewed the policy and reeducated clinical staff on the 7 day follow up call at discharge during clinical meeting on 8/25/26. Clinical Supervisor will monitor ongoing compliance monthly; completing chart reviews and audits. |