INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel training records, the facility failed to document individual training plans by December of each year, as per facility policy, in four of four personnel records.
The findings include:
Twelve personnel training records were reviewed on January 3 - 5, 2012. Four personnel training records were reviewed for individual training plans for the 2011 training year. Eight personnel training records pertained to new employees. Per facility policy, training plans will be completed by the end of each year in December. The facility's training year is from January through December. Training plans were reviewed for the 2011 training year and were due to be completed no later than December 31, 2010.
The facility failed to document individual training plans by December 31, 2010 in personnel training records # 1, 2, 3 and 4. Training plans for these employees were completed between January 25 and February 9, 2011.
The facility director and human resources director were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
As a result of the recent licensing visit, Gateway Rehab's Policy and Procedure for Staff Training and Development was changed. The new P & P states that training year will be from February 1 to January 31. Therefore the 2012 - 2013 training year begin February 1, 2012 and ends January 31, 2013.
The change also specifically states that supervisory staff will develop an annual training plan for each of the employees in their department. The calendar includes individual training needs, the topics and number of hours of training required by various outside sources, licensing and regulatory groups, and internal and external training events. The Human Resources staff will assist the supervisors in the development of these training calendars.
The 2012 calendars were forwarded to the supervisory staff were due by 2/1/2012.
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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 the facility's policy and procedure manual and client records, the facility failed to document follow-up information in one of one partial hospitalization client records.
The findings include:
Seventeen client records were reviewed on January 9 and January 30, 2012. Seven client records pertained to the partial hospitalization activity. Four client records were closed. One client record required documentation of a follow-up attempt. Per agency policy, a follow-up will be conducted within six months of discharge. The facility failed to conduct a follow-up within six months of discharge in client record # 4.
Client # 4 was admitted into treatment on April 7, 2011 and discharged on May 16, 2011. A follow-up attempt was due to be completed no later than November 16, 2011. The facility failed to provide documentation of a follow-up attempt as of January 30, 2012.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the January 14, 2010 and January 10, 2011 licensing inspections.
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Plan of Correction
Based on the recent licensing visit, it was determined that the consents for follow-up contacts were not consistently being completed with all patients.
As of 2/6/2012, the admissions staff at all levels of care will complete the consent for follow-up contacts with every patient that is admitted.
Regarding transfers from to any satellite facility, these consents will again be completed upon admission to the satellite, before the hard copy medical record chart arrives at that site, to ensure that a completed consent will be included in each patient's medical record.
With the consents available, the assigned staff that will make the follow-up attempts will be able to do so with all discharged patients. In turn, the needed documentation of the follow-up attempts will be placed in the respective patient charts.
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709.92(a)(2) 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:
(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 two of six outpatient client records.
The findings include:
Seventeen client records were reviewed on January 9 and January 30, 2012. Ten client records pertained to the outpatient activity. Six client records included an individual treatment and rehabilitation plan. The facility failed to document the type and frequency of treatment and rehabilitation services in client records # 10 and 15.
Client # 10 was admitted into treatment on April 12, 2011. An individual treatment and rehabilitation plan was developed with the client on April 12, 2011. The treatment plan indicated the client would receive one hour of individual counseling. The treatment plan failed to document the frequency of the individual sessions.
Client # 15 was admitted into treatment on September 10, 2011. An individual treatment and rehabilitation plan was developed with the client on October 1, 2011. The treatment plan did not specify the type or frequency of treatment and rehabilitation services.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Outpatient treatment plans will specifiy the type and frequency of treatment services to be provided.
Regarding treatment plans related to those patients enrolled in outpatient group programs, the treatment plans will specify that the patient will receive a specific number and frequency of group sessions and 1 individual sessions/every 60 days (or 1/two months).
Beginning immediately, the assigned counselor and the clinical manager will ensure that each patient receives the prescribed frequency of modality each week (when in attendance) and that the patient's medical record reflects documentation of all sessions conducted and/or the patient's absence.
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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 the proposed type of support service in the individual treatment and rehabilitation plan in three of six outpatient client records.
The findings include:
Seventeen client records were reviewed on January 9 and January 30, 2012. Ten client records pertained to the outpatient activity. Six client records required documentation of the proposed type of support service in the treatment and rehabilitation plan. The facility failed to document the proposed type of support service in client records # 10, 14 and 15.
Client # 10 was admitted into treatment on April 12, 2011 and discharged on April 25, 2011. The individual treatment and rehabilitation plan was completed on April 12, 2011. The treatment plan did not include the proposed type of support service.
Client # 14 was admitted into treatment on August 29, 2011. The individual treatment and rehabilitation plan was completed on August 29, 2011. The treatment plan did not include the proposed type of support service.
Client # 15 was admitted into treatment on September 10, 2011. The individual treatment and rehabilitation plan was completed on October 1, 2011. The treatment plan did not include the proposed type of support service.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
On February 7, 2012, the clinical manager conducted a staff meeting and provided an in-service on writing treatment plans. Multiple case examples were used with example treatment plans that demonstrated documentation of the proposed type of support services.
Also individual supervision sessions occurred for further treatment plan training. On February 13, 2012, at another staff meeting, additional discussion and written examples were shared to solidify appropriate, quality documentation is occurring.
All clinical staff members are now aware of the need to include appropriate support services in treatment plans. Ongoing individual supervision and chart auditing will occur to ensure that appropriate, treatment plan composition continues.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan prior to discharge in two of four outpatient client records.
The findings include:
Seventeen client records were reviewed on January 9 and January 30, 2012. Ten client records pertained to the outpatient activity. Four outpatient client records were closed. Two client records required documentation of an aftercare plan. Per facility policy, an aftercare plan will be completed with the client prior to discharge. The facility failed to document an aftercare plan prior to discharge in client records # 10 and 11.
Client # 10 was admitted into treatment on April 12, 2011 and successfully completed treatment on April 25, 2011. Client record # 10 did not include an aftercare plan.
Client # 11 was admitted into treatment on February 28, 2011 and successfully completed treatment on May 18, 2011. Client record # 11 did not include an aftercare plan.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
On February 7 , 2012, the Clinical Manager, conducted a staff meeting with clinical staff, which included a review of the regulatory standard and facility's policy on aftercare plans.
This review instructed staff to complete an aftercare plan with all patients that have completed the prescribed treatment plans and related treatment activities; and that the aftercare plans will not only be written, but also signed and dated by the patient and a staff member.
The Clinical Manager will include this documentation in her monthly patient chart audits to ensure that they are consistently being done.
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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 the facility's policy and procedure manual and client records, the facility failed to document follow-up information in three of three outpatient client records.
The findings include:
Seventeen client records were reviewed on January 9 and January 30, 2012. Ten client records pertained to the outpatient activity. Four client records were closed. Three client records required documentation of a follow-up attempt. Per agency policy, a follow-up will be conducted within six months of discharge. The facility failed to conduct a follow-up within six months of discharge in client records # 8, 10 and 11.
Client # 8 was admitted into treatment on May 11, 2011 and discharged on June 2, 2011. A follow-up attempt was due to be completed no later than December 2, 2011. The facility failed to provide documentation of a follow-up attempt as of January 30, 2012.
Client # 10 was admitted into treatment on April 12, 2011 and discharged on April 25, 2011. A follow-up attempt was due to be completed no later than October 25, 2011. The facility failed to provide documentation of a follow-up attempt as of January 30, 2012.
Client # 11 was admitted into treatment on February 28, 2011 and discharged on May 18, 2011. A follow-up attempt was due to be completed no later than November 18, 2011. The facility failed to provide documentation of a follow-up attempt as of January 30, 2012.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the January 14, 2010 and January 10, 2011 licensing inspections.
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Plan of Correction
Based on the recent licensing visit, it was determined that the consents for follow-up contacts were not consistently being completed with all patients.
As of 2/6/2012, the admissions staff at all levels of care will complete the consent for follow-up contacts with every patient that is admitted.
Regarding transfers from to any satellite facility, these consents will again be completed upon admission to the satellite, before the hard copy medical record chart arrives at that site, to ensure that a completed consent will be included in each patient's medical record.
With the consents available, the staff assigned to make the follow-up attempts will be able to do so with all discharged patients. In turn, the needed documentation of the follow-up attempts will be placed in the respective patient charts.
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