INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 7, 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 - Marietta 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed. There was a space heater located in a counselor office on the second floor of the administrative building at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 705.8(2), the following will be implemented:
Beginning on 3/21/23, all staff will adhere to the regulation of not utilizing space heaters in their offices that are not permanently mounted or installed.
The Clinical Director will monitor this action step while completing weekly walk throughs of the facility. |
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.
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Observations
Based on a review of the facility's policy and procedure manual and client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client record reviewed.
Per the policy and procedure manual, the program will contact the participant's emergency contact within 12 hours when the participant leaves treatment against facility advice.
Client #5 was admitted on November 25, 2022 and was discharged against facility advice on February 2, 2023. There was no attempted emergency contact notification documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.24(a) (3), the following will be implemented:
Beginning on 3/21/23 the Clinical Supervisor will train the clinicians and support staff on contacting clients emergency contact within 12 hours of a client leaving treatment prematurely, or is therapeutically discharged. This contact will be documented in the clients discharge summary or in the clients contact log.
The Clinical Director will monitor this action step by auditing each client's record who has left treatment prematurely, or who has been therapeutically discharged. |
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 ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in three of seven applicable client records reviewed.
Client #1 was admitted on November 7, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on November 9, 2022 and the first update was due no later than December 9, 2022; however, the update was not completed until December 14, 2022. Additionally, the next update was due no later than January 14, 2023; however, the update was not completed until January 24, 2023.
Client #3 was admitted on December 14, 2022 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on December 15, 2022 and the first update was due no later than January 15, 2023; however, the update was not completed until January 30, 2023.
Client #5 was admitted on November 25, 2022 and was discharged on February 2, 2023. The individual treatment and rehabilitation plan was completed on November 28, 2022 and the first update was due no later than December 28, 2022; however, the update was not completed until February 1, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.52(b), the following will be implemented:
Beginning on 3/21/23, each clinician will ensure that treatment plans are reviewed and updated every 30 days. Clinicians will be trained by the Clinical Supervisor to review treatment plans with the client on a weekly basis during their individual session to ensure treatment plans are not late.
The Clinical Supervisor will monitor this action step when completing the monthly chart audit. |