INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 18, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gateway Greentree 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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709.93(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 a review of client records, the facility failed to document case consultation notes in three of seven client records.
Client records #1, 3 and 5 did not include documentation of case consultations at least quarterly.
Client #1 was admitted on February 13, 2020 and is currently an active client. There were no case consultations documented since August 19, 2020 for client #1.
Client #3 was admitted on April 15, 2020 and is currently an active client. There were no case consultations documented since August 6, 2020 for client #3.
Client #5 was admitted on December 28, 2020 and discharged on April 14, 2021. There were no case consultations documented for client #5.
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. |
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, the facility failed to document follow up information in one of one client records.
One client record required follow up contact. Client record #7 did not have documentation of follow up contact.
Client #7 was admitted on January 28, 2020 and discharged on February 9, 2021. There was no follow up documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway has re-educated administrative staff on the need to track patient discharges and document follow up attempts and results. A standardized procedure has been implemented to track patient discharges and ensure each patient is contacted within the six month window. Program director and director of medical records will monitor charts to ensure all discharged patients who consent to follow up are contacted and contact is documented. This deficiency has already been corrected. |