INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14-15, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Erie 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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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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/or frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of four client records.
The findings include:
The individual treatment and rehabilitation plans for four inpatient clients were reviewed on November 15, 2013. The facility failed to document the type and/or frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in client records #2 and 3.
Client #2 was admitted on October 22, 2013 and the individual treatment and rehabilitation plan was completed on November 4, 2013. The client's treatment plan included group therapy; however, the facility failed to document the frequency of group therapy on the treatment plan.
Client #3 was admitted on September 30, 2013 and the individual treatment and rehabilitation plan was completed on October 16, 2013. The client's treatment plan included individual therapy; however, the facility failed to document the frequency of individual therapy on the treatment plan.
These findings were reviewed and confirmed with the clinical supervisor on November 15, 2013.
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Plan of Correction
In a meeting with the Clinical Assistant Director on Tuesday November 19th, 2013, Inpatient Therapist #1,Inpatient Therapist #2 and Inpatient Therapist #3 received a training to address expectations relative to documenting frequency and type of services on all treatment plans.
Therapist #1, #2 and #3 will demonstrate compliance with this standard for the next three months or until the Assistant Director/Clinical is satisfied that the standard is met.
Target date of full compliance is no later than December 15th, 2013.
The Assistant Director/Clinical will oversee compliance. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document short-term goals for treatment on the individual treatment and rehabilitation plans in five of five client records.
The findings include:
Five outpatient client records were reviewed on November 14, 2013. The facility failed to document short-term goals for treatment on the individual treatment and rehabilitation plans in client records # 8, 9, 10, 11 and 12.
The individual treatment and rehabilitation plans contained in client records # 8, 9, 10, 11 and 12 included topics to be addressed in treatment. The facility failed to document short-term goals related to the topics identified on the individual treatment and rehabilitation plans in client records # 8, 9, 10, 11 and 12.
An interview with the clinical supervisor took place on November 15, 2013 and the aforementioned information was confirmed.
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Plan of Correction
In a meeting with the Clinical Assistant Director on Tuesday November 19th, 2013, the Outpatient Therapist received training to address expectations relative to documenting short term goals on individual treatment and rehabilitation plans.
The Outpatient Therapist will demonstrate compliance with this standard for the next three months or until the Assistant Director/Clinical is satisfied that the standard is met.
Target date of full compliance is no later than December 15th, 2013.
The Assistant Director/Clinical will oversee compliance. |
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 on the individual treatment and rehabilitation plans in four of five client records.
The findings include:
The individual treatment and rehabilitation plans for five outpatient clients were reviewed on November 14, 2013. The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plans in client records # 8, 10, 11 and 12.
Client #8 was admitted on July 30, 2013 and the individual treatment and rehabilitation plan was completed on August 6, 2013. The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
Client #10 was admitted on June 26, 2013 and the individual treatment and rehabilitation plan was completed on July 17, 2013. The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
Client #11 was admitted on August 15, 2013 and the individual treatment and rehabilitation plan was completed on August 22, 2013. The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
Client #12 was admitted on October 28, 2013 and the individual treatment and rehabilitation plan was completed on November 4, 2013. The facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan.
These findings were reviewed and confirmed with the clinical supervisor on November 15, 2013.
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Plan of Correction
In a meeting with the Clinical Assistant Director on Tuesday November 19th, 2013, the Outpatient Therapist received a training to address expectations relative to documenting frequency and type of services on all treatment plans.
Outpatient Therapist will demonstrate compliance with this standard for the next three months or until the Assistant Director/Clinical is satisfied that the standard is met.
Target date of full compliance is no later than December 15th, 2013.
The Assistant Director/Clinical will oversee compliance. |