INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18, 2023 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:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide the required supervision by a trained counselor or clinical supervisor.
Employee #4 was hired as a counselor assistant on January 23, 2023 and was still employed at the time of the inspection. He had no documentation of direct observation.
Employee #5 was hired on June 5, 2023 and was still employed at the time of the inspection. He had no documentation of direct observation.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 704.9 (c), the following will be implemented:
Beginning on 12/28/2023, the Clinical Supervisor will ensure that she is facilitating weekly supervision with all counselor assistants to include direct observation. Counselor Assistants with a Associates Degree will receive weekly supervision for 9 months. Counselor Assistants with a Bachelors Degree will receive weekly supervision for 6 months.
The Clinical Director will monitor this action step during monthly supervision with the Clinical Supervisor. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to provide either individual paper towels or a mechanical dryer in each patient's bathroom. The first floor bathroom did not have either paper towels or a mechanical dryer.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.6 (2), the following will be implemented:
Beginning on 12/28/2023, the Residential Program Supervisor will ensure that all bathrooms remained fully stocked with paper towels. The Residential Program Supervisor will monitor the availability of paper towels in each bathroom during the daily walk through of the facility.
The Clinical Supervisor will monitor the progress of this action step during a weekly walk through of the facility. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store al food items off the floor. There was a box of food items on the floor in the storage area in the basement.
This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
In an effort to address citation 705.7 (b) (6), the following will be implemented:
Beginning on 12/28/2023, the Residential Program Supervisor will ensure that all food items are placed on a shelf and off of the floor. The Residential Program Supervisor will ensure that no food items are stored on the floor when completing the daily walk through of the facility.
The Clinical Director will monitor the progress of this action step while completing a weekly walk through of the facility.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee received the required training in the use of the fire extinguishers upon employment.
Employee #5 was hired on June 6, 2023 for the position of counselor assistant and was still employed at the time of the inspection. He did not have the training until June 20, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (c) (4), the following will be implemented:
Beginning on 12/28/2023, the HR Generalist will ensure that all new hires receive training regarding the use of a fire extinguisher within their first week of employment. The completion of this training will be documented and filed in the employees record.
The Executive Director will monitor the progress of this action step during monthly supervision with the HR Generalist. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee received the required training to perform assigned tasks during emergencies.
Employee #5 was hired on June 6, 2023 for the position of counselor assistant and was still employed at the time of the inspection. He did not have the training until June 20, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (d) (3), the following will be implemented:
Beginning on 12/28/2023, the HR Generalist will ensure that all new hires are trained in emergency procedures and task within their first week of employment.
The Executive Director will monitor the progress of this action step during monthly supervision with the HR Generalist. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from March 2023 through November, 2023 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on March 25, 2023 and then not again until November 18, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (d) (5), the following will be implemented:
Beginning on 12/28/2023, the Residential Program Supervisor will ensure that a fire drill is completed monthly on each shift, to include at least one fire drill on 3rd shift every 6 months.
The Clinical Director will monitor the progress of this action step during monthly supervision with the Residential Program Supervisor. |
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 inpatient client records, the facility failed to notify the emergency contact of the client leaving the facility against medical advice.
Client #5 was admitted on October 3, 2023 and discharged on November 8, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.24 (a) (3), the following will be implemented:
Beginning on 12/28/2023, the Clinical Supervisor will train all staff on how to contact a clients emergency contact and document it in the event that the client leaves treatment prematurely, or is therapeutically discharged. All clinical staff will ensure that the emergency contact person was contacted within the required 12 hour period by reviewing their assigned clients record.
The Clinical Director will monitor this action step by completing a monthly chart audit. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to complete an annual written individual staff performance evaluation, a copy of which shall be reviewed ad signed by the employee.
Employee #1 was hired as the Project Director on October 2, 2017 and was still employed at the time of the inspection. The annual evaluation for 2023 was not signed nor dated.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.26 (b) (3), the following will be implemented:
Beginning on 12/28/2023, the HR Generalist will ensure that all annual evaluations for employees are signed and dated prior to filing them in the employees record. In addition, the HR Generalist will train all supervisors across the organization to ensure that the employees annual evaluation is signed and dated prior to submitting it to the HR Generalist.
The Executive Director will monitor the progress of this action step during monthly supervision with the HR Generalist. |
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.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow up in two out of four records reviewed. The policy manual states follow up will occur at 7, 30 and 90 days.
Client #5 was admitted on October 3, 2023 and was discharged on November 8, 2023. There was no 30 day follow up completed.
Client #8 was admitted on October 21, 2023 and was discharged on November 9, 2023. There was no follow completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.53 (a) (11), the following will be implemented:
Beginning on 12/28/2023, the Program Assistant will ensure that all clients are contacted to complete a follow up at 7 days, 30 days, and 90 days post discharge. The Program Assistant will ensure that the completed follow-up is documented and filed in the clients record.
The Clinical Director will monitor the progress of this action step during monthly chart reviews and supervision with the Program Assistant. |