INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Gate House for Women 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 and a plan of correction is due on March 12, 2009.
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Plan of Correction
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705.5 (j) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(j) A residential facility shall prohibit smoking and use of candles in bedrooms.
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Observations
Based on an inspection of the facility ' s physical plant, the facility failed to prohibit the use of candles in client bedrooms.
Findings:
A physical plant inspection was conducted on January 29, 2009 at approximately 11:00 A.M. The facility was required to prohibit the use of candles in bedrooms. Candles were observed in bedrooms # 2, 4, 5 and 9.
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Plan of Correction
The Clinical Supervisor has removed all candles from entire house including bedrooms. The Clinical Supervisor will instruct all staff on the unacceptability of the use of candles in the entire house including clients' bedrooms. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on an inspection of the facility ' s physical plant, the facility failed to maintain each stairway exceeding two steps with a well secured handrail.
Findings:
A physical plant inspection was conducted on January 29, 2009 at approximately 11:00 A.M. The facility was required to maintain each stairway exceeding two steps with a well secured handrail. The facility did not have in place a handrail for stairway of the alternate basement exit.
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Plan of Correction
The Executive Director has contacted a contractor to install a handrail in the stairway of the outside exit of the basement. The handrail will be installed by April 15, 2009. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document psychosocial evaluations in three of four client records.
Findings:
Six Client records were reviewed in January 29, 2009. Psychosocial evaluations were required to be documented within 72 hours of admission, according to the facility ' s policy and procedures manual, in four client records. The facility failed to document psychosocial evaluations within 72 hours in client records # 2, 3 and 4.
Client record #2 admission date 11/07/08, psychosocial evaluation documented 11/11/08
Client record #3 admission date 09/22/08, psychosocial evaluation not documented
Client record #4 admission date 11/10/08, psychosocial evaluation documented 11/14/08
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Plan of Correction
The Clinical Supervisor will provide training to all clinical staff responsible for completing psychosocial evaluations to address the completion of psychosocial within 72 hours of admission. To ensure that this documentation is being completed with the 72 hour time frame, the Clinical Supervisor will monitor the completion of psychosocial evaluations. Full compliance will be achieved by 2/27/09. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records the facility failed to document individual treatment plans in three of three client records.
Findings:
Six client records were reviewed on January 29, 2009. Treatment plans were required to be completed within 72 hours of admission, according the facility ' s policy and procedures manual, in three client records. The facility did not document treatment plans within 72 hours in client records 1, 2 and 3.
Client record #1 admission date 10/31/08, treatment plan documented 11/07/08
Client record #2 admission date 11/07/08, treatment plan documented 11/14/08
Client record #3 admission date 09/22/08, treatment plan documented 09/26/08
Client record #4 admission date 11/10/08, treatment plan not documented
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Plan of Correction
The Clinical Supervisor will provide training to all clinical staff responsible for completing treatment plans to address the completion of treatment plans within 72 hours of admission. To ensure that this documentation is being completed with the 72 hour time frame, the Clinical Supervisor will monitor the completion of treatment plans. Full compliance will be achieved by 2/27/09. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates in three of three client records.
Findings:
Five client records were reviewed on January 29, 2009. Treatment plan updates were required in four client records. The facility failed to document treatment plan updates to include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan in client records # 1, 2, 3 and 4.
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Plan of Correction
The Clinical Supervisor will revise the treatment plan to include a specific format to include treatment plan updates. The Clinical Supervisor will train all clinical staff on the implementation of treatment plan updates. Compliance will be assured by weekly chart review by the Clinical Supervisor. Full compliance will be achieved by March 30, 2009. |
709.53(a)(2) LICENSURE Medication records
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:
(2) Medication records.
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Observations
Based on a review of client medication administration records, the facility failed to document missed medication dosages in two of four client records.
Findings:
Four client medication records were reviewed on January 29, 2009. Medication records were required to indicate the reasons for missed medication in four client records. The facility failed to document the reasons for missed medication in client records # 1 and 2.
Client record #1 prescribed Topamax 100mg, 2 times daily
The facility did not document the reason why this medication was missed on dates:
11/05/08, 11/13/08, 11/25/08
Client record #2 prescribed Buspar 15mg, 1 Tablet 3 times daily
The facility did not document the reason why this medication was missed on dates:
11/23/08, 10/26/08, 11/30/08
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Plan of Correction
The Clinical Supervisor has removed "other" as the reason why medication was missed. The Medication Log form has been changed to reflect specific reasons why medication has been missed. The Clinical Supervisor will provide training to all staff members responsible for monitoring clients taking medication for proper documentation. Clinical Supervisor will assure compliance by reviewing Medication Logs on a weekly basis. Fulll compliance will be achieved by 3/15/09. |