INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on September 10, 2021 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of five personnel files and the Staffing Requirements Facility Summary Report on September 10, 2021, the facility failed to ensure that all counselors were trained in HIV/AIDS and TB/STD within the first year of employment and all other staff within the first two years.
Staff #5 was hired on April 24, 2019 as a Support Staff. Staff #5 did not have documentation of the six hours of mandatory HIV/AIDS training or four hours of mandatory TB/STD training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 704.11 the following will be implemented:
Beginning on 9/24/2021 the Residential Program Supervisor will ensure that all support staff adhere to the training regulations. Specifically, the RPS will ensure that all support staff attend HIV/AIDS training within the first two years of hire.
The Clinical Director will monitor this requirement on a quarterly basis with the assistance of the Program Assistant who will maintain a living document that includes all staff trainings. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical site inspection on September 10, 2021, the facility failed to ensure that all toilet and wash rooms were ventilated by an exhaust fan or window.
The exhaust fan was not working in the third floor bathroom nor was there a window in that bathroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.6 the following will be implemented:
Beginning on 10/01/2021, the Residential Program Supervisor will ensure that the facility meets all physical plant standards, including working ventilated exhaust fans in each restroom. The RPS will contact the maintenance department to inform them of any needed maintenance issues. The maintenance department will install a working ventilated exhaust fan in the restroom on the 3rd floor by 10/1.
The Clinical Director will monitor this procedure monthly by completing a facility walk through. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of seven client records on September 10, 2021, the facility failed to include discharge summaries in two out of three applicable records reviewed.
Client #6 was admitted on April 6, 2021 and was discharged on July 2, 2021. There was no documentation of a discharge summary in the client record.
Client #7 was admitted on March 9, 2021 and was discharged on July 26, 2021. There was no documentation of a discharge summary in the client 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 709.53 the following will be implemented:
Beginning on 9/24/2021 the Clinical Supervisor will ensure that each client record includes a discharge summary within 14 days following the clients discharge date. The Clinical Supervisor will monitor this procedure during the monthly chart audits.
The Clinical Director will oversee the progress of this action plan by reviewing the completed monthly chart reviews. |
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 seven client records on September 10, 2021, the facility failed to include follow up information in one out of three applicable records reviewed.
Client #7 was admitted on March 9, 2021 and was discharged on July 26, 2021. There was no documentation of follow up information in the client 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 709.53 the following will be implemented:
Beginning on 9/24/2021 the Program Assistant will complete and document follow up contacts with all clients post discharge, within the following intervals: 7 days, 30 days, and 90 days.
The Clinical Director will monitor this progress by completing a monthly audit during the scheduled monthly supervision meetings with the Program Assistant. |