INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 7-11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center Inc. Moffett House 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
|
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.
|
Observations
Based on a review of patient records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven patient records reviewed.
Client #2 was admitted on July 12, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on July 12, 2022. An updated treatment plan was due no later than August 12, 2022; however, was completed on September 13, 2022.
Client #4 was admitted on August 9, 2022 and was still active at the time of the inspection. A comprehensive treatment plan was completed on August 9, 2022. An updated treatment plan was due no later than September 9, 2022; however, was completed on September 13, 2022.
Client #7 was admitted on April 26, 2022 and was discharged on July 29, 2022. A comprehensive treatment plan was completed on April 26, 2022. An updated treatment plan was due no later than May 26, 2022; however, was completed on May 31, 2022.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Therapists will meet with clinical manager on 11/2/22 to discuss updated treatment plan requirements. During weekly clinical staff meetings, manager and clinical team, will discuss pending treatment plan updates. Therapists will use EMR calendar as a reminder of pending treatment plan updates. Upon completion of updated treatment plans and client signature, therapist will message facility manager of treatment plans being completed.
The clinical manager will conduct monthly audits of treatment plans ensuring of completion in timely manner. If, treatment plans continue to be late therapist, manager and director of facility will meet to discuss and develop plan of action.
|
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.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow up documentation in three out of three applicable records reviewed.
Client #5 was admitted on January 18, 2022 and discharged on February 8, 2022.
Client #6 was admitted on March 9, 2022 and discharged on June 2, 2022.
Client #7 was admitted on April 26, 2022 and discharged on July 29, 2022.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The director of facility will meet with clinical manager on 11/10/22, regarding follow ups being completed within 30 days post discharge.
Upon admission, client will be asked if they would consent to follow up after discharge from facility. If agreed, they will sign follow up consent located in EMR. The clinical manager will be required to complete follow-up call, to clients within 30 days. The clinical manager will a maintain a roster of discharges and follow up time frames. The facility manager upon completion of follow call will document call in client EMR.
Gateway's Medical Records Department will monitor follow up consents and send reminder to manager & director of needed follow ups. Director of facility will follow up with manager monthly around status of completion of post discharge follow ups calls.
|