INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9, 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the February 2022 through February 2023 fire drill logs, the facility failed to conduct an unannounced fire drill at least one time a month as there were no fire drills conducted during the months of April, June, September, and December 2022.
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), the following will be implemented:
Beginning on 3/15/23, the Residential Program Supervisor will ensure that the fire drills are completed 1x per month on rotating shifts, utilizing a different exit in each event, and recording the time that it takes to evacuate the facility. Each completed fire drill will be documented.
The Clinical Director will monitor this action step during monthly supervision with the Residential Program Coordinator. |
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 #4 was admitted on July 12, 2022 and was discharged against facility advice on October 19, 2022. 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 3/15/23, the Clinical Director will ensure that all staff are trained in the the procedure of contacting the clients identified emergency contact within 12 hours of the client leaving treatment prematurely, or being therapeutically discharged. This training will also include how and where the contact made is documented in the clients record.
The Clinical Director will monitor the progress of this action step by auditing each clients record if and when a client leaves prematurely, or is therapeutically discharged.
The Director of Programs will monitor this action step during the monthly directors meeting. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one of one applicable record reviewed.
Client #5 was admitted on August 8, 2022 and was administratively discharged on September 22, 2022. There was no documentation in the record indicating that the client was provided written notification of the facility's decision to involuntarily terminate treatment.
This is a repeat citation from the February 9, 2022 annual licensing renewal inspection.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.33(a), the following will be implemented:
Beginning on 3/21/23, all clinicians will ensure that an "Involuntary Termination" notice is completed and given to the clients if and when a client is prematurely discharged from treatment.
The Clinical Supervisor will monitor this action step by viewing the clients record each time a client is prematurely discharged. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client record reviewed.
Client #5 was admitted on August 8, 2022 and was administratively discharged on September 22, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.33(b), the following will be implemented:
Beginning on 3/21/23, all clinicians will ensure that an "Involuntary Termination" notice is completed and given to the client, so that the client has the opportunity to request reconsideration of his treatment stay.
The Clinical Supervisor will monitor this action step by viewing the clients record each time a client is prematurely 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 project failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in six of seven client records reviewed.
Client #1 was admitted on October 24, 2022 and was active at the time of inspection. A treatment plan update was completed on December 21, 2022 and the next update was due no later than January 21, 2023; however, the update was completed on January 25, 2023.
Client #3 was admitted on January 26, 2023 and was active at the time of inspection. The individual treatment and rehabilitation plan was completed on February 1, 2023 and the first update was due no later than March 1, 2023; however, the update was completed on March 7, 2023.
Client #4 was admitted on July 12, 2022 and was discharged on October 19, 2022. A treatment plan update was completed on September 13, 2022 and the next update was due no later than October 13, 2022; however, the update was not completed prior to discharge.
Client #5 was admitted on August 8, 2022 and was discharged on September 22, 2022. The individual treatment and rehabilitation plan was completed on August 10, 2022 and the first update was due no later than September 10, 2022; however, the update was not completed prior to discharge.
Client #6 was admitted on May 16, 2022 and was discharged on August 22, 2022. A treatment plan update was completed on June 15, 2022 and the next update was due no later than July 15, 2022; however, the update was completed on July 28, 2022.
Client #7 was admitted on March 7, 2022 and was discharged on August 19, 2022. The individual treatment and rehabilitation plan was completed on March 9, 2022 and the first update was due no later than April 9, 2022; however, the update was completed on April 29, 2022. Additionally, the next update was due no later than May 29, 2022; however, the update was completed on June 7, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.52(b), the following will be implemented:
Beginning on 3/15/23, the Clinical Supervisor will ensure that all treatment plan updates are reviewed and updated every 30 days. The Clinical Supervisor will monitor this action step bi-weekly.
The Clinical Director will monitor the progress of this action step during monthly supervision with the Clinical Supervisor.
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