INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gateway Greensburg 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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709.28 (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.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent form for the disclosure of information contained in the client record, in seven of eight client records.
Client # 1, admitted on April 7, 2021 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client. Correspondence was released to the third-party payer without a valid release.
Client # 3, admitted on October 29, 2020 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client. Correspondence was released to the third-party payer without a valid release.
Client # 4, admitted on March 28, 2021 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client. Correspondence was released to the third-party payer without a valid release.
Client # 5 admitted and discharged on May 26, 2021, documented releases of information for the disclosure of information that did not include a dated signature of the client. Correspondence was released to the third-party payer without a valid release.
Client # 6, admitted on October 20, 2020 and discharged on January 21, 2021, documented releases of information for the disclosure of information that did not include a dated signature of the client. Correspondence was released to the third-party payer without a valid release.
Client # 7, admitted on December 16, 2020 and discharged on March 12, 2021, documented releases of information for the disclosure of information that did not include a dated signature of the client. Correspondence was released to the third-party payer without a valid release.
Client # 8, admitted on March 22, 2021 and discharged on June 27, 2021, documented releases of information for the disclosure of information that did not include a dated signature of the client. Correspondence was released to the third-party payer without a valid release.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Gateway will be implementing an electronic signature solution for telehealth only patients who do not return mailed paper consents. Gateway will not begin treatment until consents are electronically signed and received for these patients. Program director and director of medical records will monitor charts to ensure all records contain releases of information signed by patients. Electronic signature system will be implemented by 7/15/21. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent form that included the dated signature of client, in seven of eight client records.
Client # 1, admitted on April 7, 2021 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 3, admitted on October 29, 2020 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 4, admitted on March 28, 2021 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 5 admitted and discharged on May 26, 2021, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 6, admitted on October 20, 2020 and discharged on January 21, 2021, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 7, admitted on December 16, 2020 and discharged on March 12, 2021, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 8, admitted on March 22, 2021 and discharged on June 27, 2021, documented releases of information for the disclosure of information that did not include a dated signature of the client.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Gateway will be implementing an electronic signature solution for telehealth only patients who do not return mailed paper consents. Gateway will not begin treatment until consents are electronically signed and received for these patients. Program director and director of medical records will monitor charts to ensure all records contain releases of information signed by patients. Electronic signature system will be implemented by 7/15/21. |
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 a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in six of the six records reviewed in the partial hospitalization activity.
Client # 1 was admitted on April 7, 2021 and was still an active client at the time of the inspection. There were no individual sessions documented for the weeks of April 25-May 1, May 2-8, May 16-22, May 30- June 5, June 6-12, and June13-19, 2021. There was one individual session documented for the weeks of May 9-15 and May 23-29, 2021.
Client # 2 was admitted on June 14, 2021 and still an active client at the time of the inspection. There was one individual session documented for the weeks of June 13-18 and June 20-26, 2021.
Client # 5 admitted January 19, 2021 and transferred to outpatient services on March 5, 2021. There were no individual sessions documented for the time frame of January 19 to March 5, 2021.
Client # 6, admitted on October 20, 2020 and transferred to outpatient services on December 24, 2020. There was one individual session documented for the weeks of November 15-21 and November 22-28, 2021.
Client # 7, admitted on December 16, 2020 and transferred to outpatient services on February 1, 2021. There were no individual sessions documented for the weeks of December 20-26, 2020. There was one individual session documented for the weeks of December 27-January 2, January 3-9, January 17-23, and January 25-29, 2021.
Client # 8, admitted on March 22, 2021 and transferred to outpatient services on May 30, 2021. There were no individual sessions documented for the time frame of March 28 to May 29, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway has re-educated therapy staff on the need for twice weekly individual therapy sessions for partial patients. Individual sessions will be given twice weekly, for a minimum of thirty minutes each, for all patients in the partial level of care. Program manager will monitor patient charts during treatment and during weekly staff meetings to ensure sufficient individual sessions have been delivered. This deficiency has already been corrected. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultation notes per facility policy in three of six client ' s records reviewed in the outpatient level of care.
Facility policy states case consults are to be completed at admit, step-down and at treatment plan reviews.
Client # 3 was admitted on October 29, 2020 and was still an active client at the time of the inspection. Treatment plan reviews were completed on April 5 and June 4, 2021. Case consultation notes were to be completed at treatment plan reviews. There were no case consultations documented.
Client # 6 was admitted to the partial hospitalization program on October 20, 2020 and transferred to the outpatient level of care on December 24, 2020. Client was discharged on January 21, 2021. Treatment plan reviews were completed on December 7 and December 24, 2020. Case consultation notes were to be completed at treatment plan reviews. There were no case consultations documented.
Client # 7 was admitted to the partial hospitalization program on December 16, 2021 and transferred to the outpatient level of care on March 12, 2021. Client was discharged on March 12, 2021 Treatment plan reviews were completed on January 27 and March 12, 2021. Case consultation notes were to be completed at treatment plan reviews. There were no case consultations documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway has re-educated therapy staff on the need to document case consultations in the patient record. Case consultations will be documented at admission, level of care changes, and discharge. Program managers will monitor patient charts during treatment and at discharge to ensure regular case consultations are being documented. This deficiency has already been corrected. |