INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 19-21, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, The Gatehouse 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:
|
Plan of Correction
|
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.
|
Observations
During a physical plant inspection conducted on March 19-21, 2019, the facility failed to provide documentation of a sleeping hours fire drill conducted at least every six months. The fire drill log beginning January 14, 2018 and ending January 11, 2019 indicated one sleeping fire drill conducted on September 26, 2018. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 705.10 Fire Safety, the following will be implemented:
Beginning 4/15/2019 the Clinical Director will ensure that the fire drills are conducted during the hours that the residents are asleep at least once every 90 days. The fire drills will be unannounced and conducted between the hours of 1:00a.m. and 5:00a.m.
The Director of Programs will monitor this procedure to ensure that the Gate House for Women are adhering to this standard. |
709.28 (c) 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.
|
Observations
Based on a facility inspection conducted on March 19-21, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 7.Client # 7 was admitted on December 21, 2018 and was still an active client at the time of the inspection. Client identifying information was released on three different occasions dated December 24, 2018, February 7 and 11, 2019 to individuals without valid consent forms. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 709.28 under confidentiality the following procedures will take effect.
Director of Programs has created a new release of information form that will be utilized through out the Gate House. The new release of information form specifically inquires about the organization and the individuals name to release information to. Beginning 4/16/2019 the Clinical Director will inform and train her staff on the new form. In addition, the Clinical Director will ensure that all staff are completing the releases of information correctly. Clinical Director will also ensure that the staff do not release confidential information to anyone without the clients consent.
Director of Programs will monitor the implementation of this procedure and insure its effectiveness. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
During a facility inspection conducted on March 19-21, 2019, the facility failed to provide documentation of an inspection, at least quarterly, showing an inventory of all medications including PRN's being stored in the facility.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 709.32 Medication Control the following procedure will be implemented:
The Clinical Director and the Residential Program Supervisor will inspect all medications onsite on a monthly basis, this inspection will include over the counter medications. In addition, the monthly inspection will be documented, along with the documentation of any medications that would need to be discarded. This new procedure will begin on 4/16/2019.
The Director of Programs will monitor the progress of this procedure. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
During a facility inspection conducted on March 19-21, 2019, the facility failed to provide documentation of verification that work done by the client at the project is an integral part of his/her treatment and rehabilitation plan in Client record #'s 1, 2,3,4, 5, 6, and 7. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
In an effort to address citation 709.53 Work as Treatment the following will be implemented:
The Director of Programs has updated the client treatment plan template to include work therapy. The Clinical Director will ensure that all clinicians begin using the updated treatment plan to reflect the frequency of work therapy which is utilized to build on life skills at the Gate House. All clinicians will begin documenting work therapy on client treatment plans beginning 4/16/2019.
The Director of Programs will monitor the progress of this procedure. |