INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14-15, 2010 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 and a plan of correction is due on February 12, 2010.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on the review of personnel records and an interview with the facility director and clinical supervisor, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of five personnel records.
Findings:
Eight personnel records were reviewed on January 4-5 and January 14-15, 2010. An interview with the facility director and clinical supervisor occurred on January 15, 2010. Five personnel records were required to have completed at least 25 clock hours of training annually. The facility did not document 25 clock hours of annual training in personnel # 5.
In personnel record # 5, the staff was hired on December 28, 2008. She was required to complete at least 25 clock hours of training in 2009. There were only 11.5 training hours documented for 2009.
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Plan of Correction
THERAPY MANAGER AND REGIONAL DIRECTOR WILL CONTACT HR DEPT. TO REVIEW RECORD FOR VERIFICATION OF TRAINING AND ANNUAL TRAINING PLAN BY 2/28/10. MANAGER WILL MEET WITH STAFF EACH WEEK AND TRACK TRAINING HOURS TO ENSURE ALL HOURS ARE MET. A TRACKING SHEET HAS BEEN DEVELOPED AND TRACKING OF HOURS WILL BE FORWARDED TO HR. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on review of the documented fire drills and an interview with the facility director and clinical supervisor, the facility failed to document that a fire alarm or smoke detector was activated during each monthly fire drill.
Finding:
The fire drill logs were reviewed on January 15, 2010. The interview with the facility director and clinical supervisor occurred on January 15, 2010. There was no documentation that the fire alarm or smoke detector was activated during each monthly fire drill for drills conducted February 2009- January 2010. There was no documentation that the Department had approved an alternative procedure.
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Plan of Correction
PROGRAM DIRECTOR WILL SUBMIT A LETTER TO THE STATE LICENSING BOARD REQUESTING DISPENSATION FROM THE REQUIREMENT TO SET OFF FIRE ALARMS AS THIS PROGRAM IS LOCATED IN A BUILDING WITH OTHER TENANTS AND A SYSTEM-WIDE FIRE ALARM. THE LETTER WILL BE SUBMITTED BY 2/28/10. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 the review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of five client records.
Findings:
Eleven client records were reviewed on January 14-15, 2010. Five client records were reviewed as partial hospitalization records. Five partial hospitalization client records were required to have the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan. The facility did not document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in client records # 6, 7 and 8.
In client records # 6, 7 and 8, there was no documentation on the individual treatment and rehabilitation plan that indicated the type and frequency of treatment and rehabilitation services the client was to be receiving.
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Plan of Correction
CLINICAL MANAGER HAS HELD AN INSERVICE FOR CLINICAL STAFF ON 1/19/10 TO REVIEW CURRENT TREATMENT PLAN DOCUMENTATION REGULATIONS AND SUGGESTED CHANGES IN DESCRIPTION AND FREQUENCY OF TREATMENT DELIVERED. CLINICAL MANAGER WILL REVIEW CHARTS MONTHLY TO ENSURE APPROPRIATE DOCUMENTATION OF SERVICE DELIVERY. |
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 personnel records and interviews with the human resource manager, facility director and clinical supervisor, the facility failed to document follow-up information per facility policy in two of two client records.
The findings include:
Eleven records were reviewed on January 4-5 and 14-15, 2010. Interviews with the human resource manager took place on January 5 and January 15, 2010 and with the clinical supervisor on January 14 and 15, 2010. An interview with the facility director occurred on January 15, 2010. Five client records were reviewed as partial hospitalization records. Policy states the the client will receive follow up contact at 1, 3, 6 and 12 months after discharge. Two partial hospitalization client records were required to have follow-up information completed. The facility did not document follow up information in client records # 1 and 2.
Client # 1 was admitted on April 28, 2009 and discharged on June 12, 2009. Follow up contacts were due on July 12, September 12 and December 12, 2009. There was no documentation that follow up contacts had been attempted or made.
Client # 2 was admitted on August 18, 2009 and discharged on October 10, 2009. Follow up contacts were due on November 10, 2009 and January 10, 2010. There was no documentation that follow up contacts 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 Program Director will review this process with the Director of Research and Evalution for all patients throughout the year.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records, and interviews with the human resource manager, facility director and clinical supervisor, the facility failed to document staff work performance evaluations per facility policy in two of five personnel records.
The findings include:
Eight personnel records were reviewed on January 4-5 and 14-15, 2010. An interview with the human resource manager took place on January 5, 2010 and with the clinical supervisor on January 14 and 15, 2010. An interview with the facility director occurred on January 15, 2010. Work performance evaluations were required in five personnel records. Policy states that staff will be receive a six month probationary evaluation and an annual evaluation there after. The facility did not document staff work performance evaluations per policy, in personnel records # 2 and 5.
In personnel record #2, the staff person was hired on March 1, 1982. There was no documentation that the staff person had received his annual evaluation in 2009.
In personnel record #5, the staff person was hired on December 8, 2008. There was no documentation that the staff person had received her six month probationary evaluation which was due by June 8, 2009 or an annual evaluation in 2009.
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Plan of Correction
FACILITY DIRECTOR AND CLINICAL MANAGER WILL CONTACT THE HR DEPARTMENT MONTHLY TO REVIEW PERFORMANCE EVALUATIONS DUE AND ENSURE PREVIOUS MONTHS HAVE BEEN COMPLETED IN A TIMELY MANNER. ALL PERFORMANCE EVALUATIONS WILL BE SIGNED BY PROGRAM DIRECTOR OR VICE PRESIDENT OF TREATMENT. INSTITUTION OF THIS PROCEDURE BEGAN ON 1/19/10. |
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 personnel records and interviews with the human resource manager, facility director and clinical supervisor, the facility failed to document follow-up information per facility policy in three of three client records.
The findings include:
Eleven records were reviewed on January 4-5 and 14-15, 2010. Interviews with the human resource manager took place on January 5 and January 15, 2010 and with the clinical supervisor on January 14 and 15, 2010. An interview with the facility director occurred on January 15, 2010. Six client records were reviewed as outpatient records. Policy states the the client will receive follow up contact at 1, 3, 6 and 12 months after discharge. Three outpatient client records were required to have follow-up information completed. The facility did not document follow up information in client records # 3, 4 and 5.
Client # 3 was admitted on June 9, 2009 and discharged on November 3, 2009. Follow up contact was due on December 3, 2009. There was no documentation that follow up contact had been attempted or made.
Client #4 was admitted on February 26, 2009 and discharged on October 15, 2009. Follow up contact was due on November 15, 2009. There was no documentation that follow up contact had been attempted or made.
Client # 5 was admitted on April 20, 2009 and discharged on June 18, 2009. Follow up contact was due on July 18, 2009, September 18, 2009 and December 18, 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 Program Director will review this process with the Director of Research and Evalution for all patients throughout the year. |