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 17, 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 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:
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Plan of Correction
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709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a dated signature of the client on each consent to release information.
Client #2 was admitted on December 14, 2020 and is currently an active client. A consent to release information to the insurance payer was signed and dated by staff on December 30, 2020. There was no dated client signature present on this consent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway will be implementing an electronic signature solution for telehealth only patients who do not return mailed paper consents. Gateway will not begin treatment until consents are electronically signed and received for these patients. Program director and director of medical records will monitor charts to ensure all records contain releases of information signed by patients. Electronic signature system will be implemented by 7/1/21. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of client records, the facility failed to document verification the client reached 18 years of age prior to the administration of an agent, buprenorphine.
Client #6 was admitted to treatment on April 14, 2020 and was prescribed buprenorphine on that same day. Client #6 was discharged on August 26, 2020. There was no documentation of an ID or verification that client #6 reach at least 18 years of age.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway will re-educate administrative staff to check and re-gather patient identification at in-person buprenorphine induction appointments, if it is not already in the file. Administrative staff will use the identification to verify the patient has reached 18 years of age. Program director and medical records staff will monitor charts to ensure all patients prescribe buprenorphine have patient identification verifying they have reached 18 years of age in their chart. Administrative staff will be re-educated by 6/25/21. Medical records staff will begin monitoring immediately. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records, the facility failed to document verification of the individual's identity, including name, address, date of birth, emergency contact and other identifying data prior to the administration of an agent, buprenorphine.
Client #6 was admitted to treatment on April 14, 2020 and was prescribed buprenorphine on that same day. Client #6 was discharged on August 26, 2020. There was no documentation of an ID or verification of the individual 's identity, including name, address, date of birth, emergency contact and other identifying data in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway will re-educate administrative staff to check and re-gather patient identification at in-person buprenorphine induction appointments, if it is not already in the file. Administrative staff will use the identification to verify the individual's identity including name, address, and date of birth. Program director and medical records staff will monitor charts to ensure all patients prescribe buprenorphine have patient identification verifying name, address and date of birth in their chart.Administrative staff will be re-educated by 6/25/21. Medical records staff will begin monitoring immediately. |
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, 2 and 3 did not include documentation of case consultations at least quarterly.
Client #1 was admitted on August 20, 2020 and is currently an active client. There were no case consultations documented for client #1.
Client #2 was admitted on December 14, 2020 and is currently an active client. There were no case consultations documented for client #2.
Client #3 was admitted on April 28, 2020 and is currently an active client. There was one case consultation dated September 3, 2020 documented in client record #3.
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 two of two client records.
Two client records required follow up contact. Client records #5 and #7 did not have documentation of follow up contact.
Client #5 was admitted on January 2, 2020 and discharged on April 2, 2020. There was no follow up documented in client record #5.
Client #7 was admitted on February 3, 2020 and discharged on May 19, 2020. 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. |