INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 13 - 17, 2010 and December 28, 2010 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 and a plan of correction is due on January 24, 2011.
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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 personnel training records and staff interviews, the facility failed to provide documentation of TB/STD training in one of three personnel training records.
The findings include:
Five personnel training records were reviewed on December 13 - 15, 2010. Three personnel training records were reviewed for documentation of TB/STD training. Per regulation, staff persons shall receive a minimum of 4 hours of TB/STD training. Counselors and counselor assistants shall complete the training within the first year of employment and all other staff shall complete the training with the first 2 years of employment. The facility did not provide documentation of TB/STD training in personnel training record # 14.
Employee # 14 is support staff and was hired July 23, 2007. TB/STD training was due to be completed no later than July 23, 2009. Verification of TB/STD training was not documented for employee # 14, at the time of the review on December 13 - 15, 2010 and December 28, 2010.
The human resources director was interviewed on December 15, 2010 and confirmed documentation of TB/STD training was not available for employee # 14. The clinical supervisor and employee # 14 were interviewed on December 28, 2010 and confirmed that TB/STD training had not been completed yet.
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Plan of Correction
The Director and Clinical Manager have completed this year's staff training plans. TB/STD training has again been included on the respective employee's annual training plan. This staff member will be scheduled to attend the necessary training by the end of the second quarter of this year (by or before June 30,2011).
Established procedures have been in place for the past 2 years. The Clinical Manager has been reminded that she must ensure the scheduling and monitoring of all facility staff trainings including the clerical support staff. She will follow the established procedures, which are noted below:
- To ensure closer monitoring of staff trainings, the Clinical Manager will create an on-site file for each staff member, including all support staff, which will include copies of training plans & training records/certificates.
- The Manager will review these records at the end of each quarter as an aid to assist staff in scheduling and completing the trainings listed on their annual plans, including required/mandatory trainings. In turn, the Manager will present a quarterly status report to the Director.
- The Manager will compare these records with HR every 6 months to ensure completeness of both files. This will assist the manager to maintain a more hands-on record of the needed trainings for each staff (both clinical and clerical).
The on-site files on all staff will be updated and/or constructed by February 11, 2011 and will be maintained by the Clinical Manager thereafter.
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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 an interview with the clinical supervisor, the facility failed to document follow-up information in two of two partial hospitalization client records.
The findings include:
Thirteen client records were reviewed on December 17 and December 28, 2010. Six client records pertained to the partial hospitalization activity. Two client records were closed and required documentation of a follow-up. Per facility policy, a follow-up will be conducted within 30 days of discharge. The facility failed to conduct a follow-up within 30 days of discharge in client records # 9 and 10.
Client # 9 was admitted into treatment on January 11, 2010 and discharged on February 8, 2010. Follow-up was due to be completed no later than March 8, 2010. Client record # 9 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 28, 2010.
Client # 10 was admitted into treatment on June 28, 2010 and discharged on July 7, 2010. Follow-up was due to be completed no later than August 7, 2010. Client record # 10 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 28, 2010.
The clinical supervisor was interviewed on December 28, 2010. Follow-ups are conducted by the research department. As of December 28, 2010, the research department did not provide verification of follow-ups on clients # 9 and 10. The clinical supervisor confirmed that follow-up documentation had not been provided for these client records.
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Plan of Correction
The Program Director will assist the VP of Therapy programs to revise the policy and procedures (P & Ps) relative to follow-up contacts with discharged patients.
The new policy will include that Gateway's satellite facilities will attempt telephone follow-up contacts for their respective discharged patients by no more than 6 months after patient discharges. This will ensure that each satellite facility will be responsible for follow-up contacts and the related documentation and that this will occur before the closed patient charts are submitted to the medical records department for storage.
Once the new P & Ps are approved by administration, each satellite facility will conduct staff training on the new P & Ps, which will be implemented by February 28, 2011.
The director will assign the administrative assistant to ensure that the follow-up contacts will be conducted as assigned. 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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709.93(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 an interview with the clinical supervisor, the facility failed to document follow-up information in two of two outpatient client records.
The findings include:
Thirteen client records were reviewed on December 17 and December 28, 2010. Seven client records pertained to the outpatient activity. Three client records were closed. Two client records required documentation of a follow-up. Per agency policy, a follow-up will be conducted within 30 days of discharge. The facility failed to conduct a follow-up within 30 days of discharge in client records # 11 and 12.
Client # 11 was admitted into treatment on June 9, 2010 and discharged on July 9, 2010. Follow-up was due to be completed no later than August 9, 2010. Client record # 11 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 28, 2010.
Client # 12 was admitted into treatment on February 23, 2010 and discharged on June 17, 2010. Follow-up was due to be completed no later than July 17, 2010. Client record # 12 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 28, 2010.
The clinical supervisor was interviewed on December 28, 2010. Follow-ups are conducted by the research department. As of December 28, 2010, the research department did not provide verification of follow-ups on clients # 11 and 12. The clinical supervisor confirmed that follow-up documentation had not been provided for these client records.
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Plan of Correction
The Program Director will assist the VP of Therapy programs to revise the policy and procedures (P & Ps) relative to follow-up contacts with discharged patients.
The new policy will include that Gateway's satellite facilities will attempt telephone follow-up contacts for their respective discharged patients by no more than 6 months after patient discharges. This will ensure that each satellite facility will be responsible for follow-up contacts and the related documentation and that this will occur before the closed patient charts are submitted to the medical records department for storage.
Once the new P & Ps are approved by administration, each satellite facility will conduct staff training on the new P & Ps, which will be implemented by February 28, 2011.
The director will assign the administrative assistant to ensure that the follow-up contacts will be conducted as assigned. 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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