INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on February 26, 2010.
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Plan of Correction
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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 and interviews with the human resource director and the facility director, the facility failed to document follow-up information per facility policy in one of three client records.
The findings included:
Twelve client records were reviewed on January 4-5 and 28, 2010. The human resource director was interviewed on January 5, 2010 and the facility director was interviewed on January 28, 2010. Five client records were reviewed as partial hospitalization client records. Policy states the the client will receive follow up contact at 1, 3, 6 and 12 months after discharge. Three partial hospitalization client records were required to have follow-up information completed. The facility did not document follow up information in client record
#4.
Client # 4 was admitted on March 23, 2009 and discharged on May 28, 2009. Follow up contact was due on June 28, 2009 and November 28, 2009 . There was no documentation that follow up contact had been attempted or made.
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Plan of Correction
Gateway is currently in the process of updating its follow-up policy. Until that is completed, the Director of Research and Evaluation will monitor the follow-up process more closely to assure it is being completed as stated in our policy.
The Regional Director will review this process with the Director of Research and Evaluation for patients in the satellite facilities, throughout the year. |
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 a review of client records and interviews with the human resource director and the facility director, the facility failed to document follow-up information per facility policy in two of two client records.
The findings included:
Twelve client records were reviewed on January 4-5 and 28, 2010. The human resource director was interviewed on January 5, 2010 and the facility director was interviewed on January 28, 2010. Seven client records were reviewed as outpatient client records. Policy states that the client will receive follow up contact at 1, 3, 6 and 12 months after discharge. Two outpatient client records were required to have follow-up information completed. The facility did not document follow up information in client records # 2 and 3.
Client # 2 was admitted on June 29, 2009 and discharged on October 8, 2009. Follow up contact was due on November 9, 2009 and January 8, 2010. There was no documentation that follow up contact had been attempted or made.
Client # 3 was admitted on July 30, 2009 and discharged on October 21, 2009. Follow up contact was due on November 21, 2009 and January 21, 2010. There was no documentation that follow up contact had been attempted or made.
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Plan of Correction
Gateway is currently in the process of updating its follow-up policy. Until that is completed, the Director of Research and Evaluation will monitor the follow-up process more closely to assure it is being completed as stated in our policy.
The Regional Director will review this process with the Director of Research and Evaluation for patients in the satellite facilities, throughout the year. |