INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Squirrel Hill 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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709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in three of four partial hospitalization client records.
The findings include:
Seven partial hospitalization client records were reviewed on January 8 and January 17, 2013. Four client records were reviewed for the type and frequency of treatment services in the individual treatment plan. The facility failed to document the type and frequency of individual counseling sessions in client records # 4, 6 and 7.
Client # 4 was admitted into treatment on November 8, 2012. The individual treatment plan was completed on November 19, 2012. The client is participating in group and individual counseling. The facility failed to document the type and frequency of individual counseling sessions in the treatment plan of client # 4.
Client # 6 was admitted into treatment on December 12, 2012. The individual treatment plan was completed on January 14, 2012. The client is participating in group and individual counseling. The facility failed to document the type and frequency of individual counseling sessions in the treatment plan of client # 6.
Client # 7 was admitted into treatment on December 17, 2012. The individual treatment plan was completed on December 22, 2012. The client is participating in group and individual counseling. The facility failed to document the type and frequency of individual counseling sessions in the treatment plan of client # 7.
The clinical supervisor and counselor were interviewed on January 17, 2013 and confirmed the findings.
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Plan of Correction
The Clinical Manager conducted and in-service on treatment plans during two consecutive staff meetings (Jan. 21 and Jan. 28, 2013). As part of the in-service the manager reviewed the regulatory standards and this citation with the staff. Type and frequency of services was one focus of review. Staff members are to specifically write the type and frequency of services as the first action step of each treatment plan. Written plans for all levels of care were exemplified for staff.
Also the Clinical Manager will review and sign all treatment plans and will now ensure that the appropriate and required type and frequency of services are written in each plan before final saved in the electronic medical record.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in two of two partial hospitalization client records. In addition, the facility failed to document a treatment plan update every 30 days in one of two partial hospitalization client records.
The findings include:
Seven partial hospitalization client records were reviewed on January 8 and January 17, 2013. Two client records were reviewed for documentation of treatment plan updates and were required to include an assessment of the client's progress in relationship to the stated goals. Per facility policy, treatment plan updates will be completed every 30 days. The facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in client records # 4 and 6. The facility failed to document a treatment plan update every 30 days in client record # 4.
Client # 4 was admitted into treatment on November 8, 2012. The comprehensive treatment plan was completed on November 19, 2012. A treatment plan update was due to be completed no later than December 19, 2012. A treatment plan update was not completed until January 14, 2013 and did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 6 was admitted into treatment on December 12, 2012. The comprehensive treatment plan was completed on December 12, 2012. A treatment plan update was completed on January 7, 2013 and did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
On 1/28/13, the Clinical Manager conducted an in-service session with the clinical staff and demonstrated how they can more completely document treatment plan updates in the agency's new EMR. The treatment plan review document is constructed whereby staff can document "notes" associated with each objective in the plan.
The Manager will review and electronically sign each treatment plan and review and will ensure that the clients' progress or lack of progress on the stated goals and objectives are included and before final saving the document.
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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 a review of client records, the facility failed to document follow-up information in one of one partial hospitalization client record.
The findings include:
Seven partial hospitalization records were reviewed on January 8 and January 17, 2013. Four client records were closed. One client record was due for a follow-up attempt. Per facility policy, a follow-up will be conducted within 6 months of the client's discharge. The facility failed to document a follow-up attempt in client record # 1.
Client # 1 was admitted into treatment on March 14, 2012 and discharged on June 8, 2012. A follow-up attempt was due to be completed no later than December 8, 2012. There was no documentation of follow-up information in client record # 1, as of January 17, 2013.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the December 28, 2010 and January 24, 2012 licensing inspections.
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Plan of Correction
In his review of this citation and the patient chart involved, the Director determined that the patient discharge occurred in June/2012. During that month the facility experienced a staff transition of work duties, which appeared to cause difficulties with identifying this patient follow-up.
The director has re-assigned the administrative assistant to ensure that the follow-up contacts will be conducted as assigned and as per the established policy and procedures.
On at least a bi-monthly basis, the Clinical Manager will monitor and compare the list of follow-up contact attempts with the corresponding list of discharged patients' charts, to ensure all patients are involve with the follow-up process.
The Administrative assistant will report the results of the follow-up contacts on, at least, a bi-monthly basis to the director.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in two of four outpatient client records. In addition, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in one of four outpatient client records.
The finding include:
Seven outpatient client records were reviewed on January 8 and January 17, 2013. Four client records were reviewed for psychosocial evaluations. Per facility policy, psychosocial evaluations are due to be completed within three counseling sessions. The facility failed to document psychosocial evaluations in client records # 12 and 13. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client in client record # 14.
Client # 12 was admitted into treatment on August 28, 2012. A psychosocial evaluation was due to be completed no later than the third session of treatment on September 11, 2012. There was no documentation of a psychosocial evaluation in client record # 12, as of January 17, 2013.
Client # 13 was admitted into treatment on October 4, 2012. A psychosocial evaluation was due to be completed no later than the third session of treatment on October 18, 2012. There was no documentation of a psychosocial evaluation in client record # 13, as of January 17, 2013.
Client # 14 was admitted into treatment on September 17, 2012. A psychosocial evaluation was completed on September 24, 2012. The psychosocial evaluation did not include a clinical assessment of the client's assets/strengths and negative factors and only included client reported historical information.
The clinical supervisor and counselor were interviewed on January 17, 2013 and confirmed the findings.
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Plan of Correction
On Jan. 28 and Feb 4, 2013, the Clinical Manager conducted in-service sessions during scheduled staff meetings. The in-services included specific reviews of the regulatory standards and Gateway's policies specfic to psychosocial evaluations. All staff where directly reminded of the time requirements of completing the psychosocial evaluation (by third clinical session after admission).
Regarding the issue of appropriately completing psychosocial evaluations to include a clinical assessment of the client's assets/strengths and negative factors, the Clinical Manager provided examples of well written documents and incomplete written documents for review and discussion.
During February and March, 2013, the
Clinical Manager will specifically audit the completeness and quality of all psychosocial evaluations composed by staff before the documents are final saved in the agency's EMR and will review her findings with the respective staff in either individual or group supervision sessions.
After this initial 2 month period, the manager will review this document on an ongoing basis as part of her routine chart audit activities as well as supervision and staffing sessions.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that included the proposed type of support service in two of four outpatient client records.
The findings include:
Seven outpatient client records were reviewed on January 8 and January 17, 2013. Four client records were reviewed for individual treatment plans and were required to include the proposed type of support services. The facility failed to document an individual treatment and rehabilitation plan that included the proposed type of support service in client records # 11, 13 and 14.
Client # 11 was admitted into treatment on November 12, 2012. The individual treatment and rehabilitation plan was completed on November 19, 2012. The treatment plan in client record # 11 did not include the proposed type of support service.
Client # 13 was admitted into treatment on October 4, 2012. The individual treatment and rehabilitation plan was completed on October 18, 2012. The treatment plan in client record # 13 did not include the proposed type of support service.
Client # 14 was admitted into treatment on September 17, 2012. The individual treatment and rehabilitation plan was completed on September 26, 2012. The treatment plan in client record # 14 did not include the proposed type of support service.
The clinical supervisor and counselor were interviewed on January 17, 2013 and confirmed the findings.
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Plan of Correction
The Clinical Manager conducted and in-service on treatment plans during two consecutive staff meetings (Jan. 21 and Jan 28, 2013). As part of the in-service the manager reviewed the regulatory standards and this citation with the staff. Including proposed type(s) of support service(s) in treatment plans was one focus of the review. Staff members are to include proposed support services in their master treatment plans for each patient. Written plans were exemplified for the staff.
Also the Clinical Manager will review and sign all treatment plans and will now ensure that appropriate support services are written in each plan before final saved in the electronic medical record.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in three of four outpatient client records. In addition, the facility failed to document a treatment plan update every 60 days in two of four outpatient client records.
The findings include:
Seven outpatient client records were reviewed on January 8 and January 17, 2013. Four client records were reviewed for documentation of treatment plan updates and were required to include an assessment of the client's progress in relationship to the stated goals. Per facility policy, treatment plan updates will be completed every 60 days. The facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in client records # 11, 13 and 14. The facility failed to document a treatment plan update every 60 days in client records # 13 and 14.
Client # 11 was admitted into treatment on November 12, 2012. The comprehensive treatment plan was completed on November 19, 2012. A treatment plan update was completed on November 23, 2012 and did not include an assessment of the client' progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 13 was admitted into treatment on October 4, 2012. The comprehensive treatment plan was completed on October 18, 2012. A treatment plan update was completed on November 8, 2012 and did not include an assessment of the client' progress in relationship to the stated goals of the comprehensive treatment plan. A second treatment plan update was due to be completed no later than January 8, 2013. There was no documentation of a second treatment plan update in client record # 13.
Client # 14 was admitted into treatment on September 17, 2012. The comprehensive treatment plan was completed on September 26, 2012. A treatment plan update was completed on November 13, 2012 and did not include an assessment of the client' progress in relationship to the stated goals of the comprehensive treatment plan. A second treatment plan update was due to be completed no later than January 13, 2013. There was no documentation of a second treatment plan update in client record # 14.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
On 1/28/13, the Clinical Manager conducted an in-service session with the clinical staff and demonstrated how they can more completely document treatment plan updates in the agency's new EMR. The treatment plan review document is constructed whereby staff can document "notes" associated with each objective in the plan.
The Manager will review and electronically sign each treatment plan and review and will ensure that the clients' progress or lack of progress on the stated goals and objectives are included and before final saving the document.
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