INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 12, 2021 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:Physical plant inspection was conducted on April 21, 2021 due to a covid 19 outbreak in the facility at the time of the original inspection date.
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on one of five employee records reviewed, teh facility failed to provide documentation of each counselor meeting the at least one of the required qualifications to be in a counselor position.Employee # 4 was hired as a counselor on January 27, 2020 and was still in this position at the time of the inspection. After a review of personnel records, employee # 4 does not have a qualifying degree by an accredited institution to be in a counselor position. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 13, 2020 inspection.
|
Plan of Correction
In an effort to address citation 704.7 (b) the following will be implemented:
Beginning on 4/30/2021, the Director of HR will ensure that each clinician hired has obtained a college degree from an accredited university. The clinician in question no longer is employed at Gate House Mountville.
The Clinical Director will monitor this progress during the time of interviews for new clinicians. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the purpose of the disclosure. Client # 6 was admitted on December 9, 2020 and was discharged on March 19, 2021. An informed and voluntary consent from the client for the disclosure of information signed and dated on December 21, 2020 to an outside organization did not provide the purpose for the disclosure.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the September 3, 2020 inspection.
|
Plan of Correction
In an effort to address citation 709.28 (c) (3) the following will be implemented:
Beginning on 4/30/2021, the clinicians, case managers, and program assistants will complete the release of information in its entirety, to include the purpose of disclosure.
The Clinical Supervisor will monitor the progress of this action step during the monthly chart review. |
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 two of three applicable discharged client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur seven days, thirty days and ninety days after discharge. Client # 6 was admitted on December 9, 2020 and was discharged on March 19, 2021. A follow-up was due to occur no later than March 26, 2021. There was no follow-up information documented in the client record. Client # 7 was admitted on April 13, 2020 and was discharged on June 27, 2020. A follow-up was due to occur no later than July 4, 2020 however, the only follow-up information documented occurred on September 24, 2020.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 709.53 (a) (11) the following will be implemented:
Beginning on 4/30/2021 the program assistant will complete the follow up contacts for each client post discharge at the following intervals: 7 days, 30 days and 90 days. The follow up contact will be documented.
The Clinical Director will monitor this action step monthly during the chart audits. |