INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 2022 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 Behavioral Health Services 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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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 personnel records, the facility failed to provide documentation of an annual written individual staff performance evaluation signed and reviewed by the employee in one of three applicable records reviewed.Employee # 2 was hired as a facility director on June 4, 2018 and was still in this position at the time of the inspection. There was no documentation of a 2021 annual performance evaluation provided in the personnel record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.26 the following will be implemented:
Beginning on 2/23/2022, the program coordinator will maintain a record of all employees hire dates, to ensure that the annual written performance evaluation plans are completed within 30 days following the anniversary of the employees hire date.
The employees direct supervisor will complete, review, and maintain a signed copy of the employees annual performance evaluation.
The human resource generalist will monitor the completion of this plan throughout the year. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on three of thirteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.Client # 4 was admitted on November 5, 2021 and was still active at the time of the inspection. A fax sent to a government agency on December 21, 2021 provided substance used, how often and the age of first use. The informed and voluntary consent from the client for the disclosure of information dated November 5, 2021 was restricted to the information allowed in 255.5 b (1-5).Client # 5 was admitted on December 14, 2021 and was discharged January 26, 2022. A fax sent to a government agency on December 14, 2021 provided substance used, how often and the age of first use. The informed and voluntary consent from the client for the disclosure of information dated December 14, 2021 was restricted to the information allowed in 255.5 b (1-5).Client # 12 was admitted on November 19, 2021 and was discharged January 14, 2022. An informed and voluntary consent from the client for the disclosure of information dated January 13, 2022 to an employer allowed for the release of the prognosis of the client, the nature of the project, a brief description of the progress of the client, and a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28, the following will be implemented:
Beginning on 2/25/2022, the Clinical Director will train the clinical staff, case managers, and program coordinator on the 5 points of confidentiality listed under 255.5 (b) (1-5). This training will include information that is and is not permitted to disclose under the specific regulations. The counselors, case managers, and/or program coordinator will ensure that each informed and voluntary consent form includes the specific information to be disclosed. Counselors and/or program coordinator will ensure that the information released is restricted to 255.5 b (1-5) regulations.
The clinical supervisor will monitor the progress of this action plan while completing monthly chart reviews. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on two of six partial hospitalization client records reviewed, the facility failed to provide documentation of individual counseling services being provided at least twice weekly in client records # 1 and # 3.Client # 1 was admitted to partial hospitalization on August 10, 2021, had a level of care change to outpatient services on January 6, 2021, and was still active at the time of the inspection. A review of progress notes indicates individual counseling sessions not being provided twice weekly the weeks of: August 17-24, August 25- 31, September 1-7, 8-14, 15-21, 22-28, 29-October 5, 6-12, 13-19, 20-26, 27-November 2, 3-9, and 10-16, 2021.Client # 3 was admitted to outpatient services on November 18, 2021, had a level of care change to partial hospitalization services on December 23, 2021, and was still active at the time of the inspection. A review of progress notes indicates individual counseling sessions not being provided twice weekly the weeks of: December 23-29, 30-January 5, and January 13-19, 2022.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 31, 2021 annual licensing inspection.
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Plan of Correction
In an effort to address citation 709.82 (d) (1) the following will be implemented:
Beginning on 2/23/2022, each counselor providing partial hospitalization services to a client, will ensure that they are facilitating an individual session two times per week. Individual sessions will be documented in the DAP format and maintained in the clients record. If the client fails to attend their scheduled individual session, the counselor will document the absence and make every attempt to reschedule the client's appointment.
The Clinical Supervisor will monitor the progress of this action plan while conducting monthly chart reviews. |
709.83(a)(4) LICENSURE Client records
709.83. 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:
(4) Case consultation notes.
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Observations
Based on two of six partial hospitalization client records reviewed, the facility failed to provide a complete client record to include case consultation notes in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate case consultations to occur at a level of care change, every thirty days, and at discharge. Client # 4 was admitted to outpatient services on November 5, 2021, had a level of care change to partial hospitalization services on December 21, 2021, and was still active at the time of the inspection. A case consultation was due at the level of care change and no later than December 5, 2021. There was not a case consultation documented in the client record. Client # 6 was admitted to outpatient services on August 13, 2021, had a level of care change to partial hospitalization services on October 27, 2021. Client #6 was discharged on December 20, 2021. A case consultation was due at the level of care change and no later than November 27, 2021. The only case consultation was documented on December 21, 2021 at discharge.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 31, 2021 annual licensing inspection.
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Plan of Correction
In an effort to address citation 709.83 (a) the following will be implemented:
Beginning on 2/23/2022, the counselors providing partial hospitalization services will ensure that a case consult is completed, reviewed, and signed at the weekly clinical meeting during the following intervals: change of level of care, every thirty days, and at discharge.
The clinical supervisor will monitor the progress of this action plan by maintaining a weekly document that identifies the due dates for each case consult review. |
709.83(a)(11) LICENSURE Client records
709.83. 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 one of one applicable partial hospitalization client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 30, 60, and 90 days by phone.Client # 6 was admitted to outpatient services on August 13, 2021, had a level of care change to partial hospitalization services on October 27, 2021. Client #6 was discharged on December 20, 2021. There was no follow-up information documented in the client record. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 31, 2021 annual licensing inspection.
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Plan of Correction
In an effort to address citation 709.83 (a) (11), the following will be implemented:
Beginning on 2/23/2022, the program coordinator will conduct a follow-up contact with each client post discharge during the following intervals: 30, 60, and 90 days. Each follow-up contact will be documented and maintained in the clients record.
The Clinical Director will monitor the progress of this action plan during monthly chart reviews. |
709.93(a)(11) LICENSURE Client records
709.93. 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 one of two applicable outpatient client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within a week for a referral, or 30, 60, and 90 days by phone after discharge.Client # 13 was admitted to outpatient services on April 28, 2021 and was discharged on November 30, 2021. There was no follow-up information documented in the client record. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 31, 2021 and February 21, 2020 annual licensing inspection.
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Plan of Correction
In an effort to address citation 709.93 (a) (11), the following will be implemented:
Beginning on 2/23/2022, the program coordinator will conduct a follow-up contact with each client post discharge during the following intervals: 30, 60, and 90 days. Each follow-up contact will be documented and maintained in the clients record.
The Clinical Director will monitor the progress of this action plan during monthly chart reviews. |