INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 13 - 17, 2010 and December 20 - 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center 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 January 19, 2011.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel training records and an interview with the facility director and human resources director, the facility failed to provide documentation of communicable disease training in fifteen of twenty personnel training records.
The findings include:
Twenty-eight personnel training records were reviewed on December 13 - 15, 2010. Twenty personnel training records were reviewed for documentation of communicable disease training. Twenty personnel training records were required to have documentation of communicable disease training. Per regulation, staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
The facility did not provide documentation of HIV/AIDS and TB/STD training in personnel training records # 18, 19, 20, 21 and 24. The facility did not provide documentation of TB/STD training in personnel records # 5, 11, 12, 17, 22, 23, 25, 26, 27 and 28.
Employee # 5 is was promoted to the position of clinical supervisor on October 16, 2010. Employee # 5 was initially hired as a counselor on August 20, 2007. TB/STD training was due to be completed no later than August 20, 2008. The facility failed to provide documentation of TB/STD training for employee # 5.
Employee # 11 is a counselor and was hired on October 5, 2009. TB/STD training was due to be completed no later than October 5, 2010. The facility failed to provide documentation of TB/STD training for employee # 11.
Employee # 12 is a counselor and was hired on December 8, 2008. TB/STD training was due to be completed no later than December 8, 2009. The facility failed to provide documentation of TB/STD training for employee # 12.
Employee # 17 is support staff and was hired October 29, 2007. TB/STD training was due to be completed no later than October 29, 2009. The facility failed to provide documentation of TB/STD training for employee # 17.
Employee # 18 is support staff and was hired January 21, 2008. HIV/AIDS and TB/STD training were due to be completed no later than January 21, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 18.
Employee # 19 is support staff and was hired October 22, 2007. HIV/AIDS and TB/STD training were due to be completed no later than October 22, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 19.
Employee # 20 is support staff and was hired January 2, 2008. HIV/AIDS and TB/STD training were due to be completed no later than January 2, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 20.
Employee # 21 is support staff and was hired September 29, 2008. HIV/AIDS and TB/STD training were due to be completed no later than September 29, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 21.
Employee # 22 is support staff and was hired January 7, 2000. TB/STD training was due to be completed no later than January 7, 2002. The facility failed to provide documentation of TB/STD training for employee # 22.
Employee # 23 is support staff and was hired October 15, 2007. TB/STD training was due to be completed no later than October 15, 2009. The facility failed to provide documentation of TB/STD training for employee # 23.
Employee # 24 is support staff and was hired October 13, 2007. HIV/AIDS and TB/STD training were due to be completed no later than October 13, 2009. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 24.
Employee # 25 is support staff and was hired September 1, 2005. TB/STD training was due to be completed no later than September 1, 2007. The facility failed to provide documentation of TB/STD training for employee # 25.
Employee # 26 is a counselor and was hired on January 14, 2008. TB/STD training was due to be completed no later than January 14, 2009. The facility failed to provide documentation of TB/STD training for employee # 26.
Employee # 27 is a counselor and was hired on December 29, 2008. TB/STD training was due to be completed no later than December 29, 2009. The facility failed to provide documentation of TB/STD training for employee # 27.
Employee # 28 is a counselor and was hired on March 24, 2008. TB/STD training was due to be completed no later than March 24, 2009. The facility failed to provide documentation of TB/STD training for employee # 28.
The facility director was interviewed on December 20 - 21, 2010 and confirmed that documentation of communicable disease training could not be located for these employees. The human resources director was interviewed on December 15, 2010 and confirmed that documentation of communicable disease training was not available in these personnel training records.
This is a repeat citation.
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Plan of Correction
Individual staff who were out of compliance for HIV/AIDS and/or TB/STD training will be required to attend training no later than 5/27/11. Clinical Managers and Supervisors will monitor for compliance. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs and an interview with the facility director and medical records director, the facility failed to document the completion of a monthly unannounced fire drill for February 2010.
The findings include:
A review of the fire drill logs was conducted on December 20, 2010. There was no documentation that a fire drill was conducted for the month of February 2010.
On December 20 - 21, 2010, the facility director reported that a fire drill was completed but confirmed that documentation of the February 2010 fire drill could not be located. The medical records director was interviewed on December 21, 2010. She reported she has been in charge of maintaining the fire drill logs since August of 2010 and confirmed she has been unable to locate the February 2010 fire drill.
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Plan of Correction
Fire drills will be held every month in 2011 and the documentation will be completed and forwarded to the Director of Medical records for filing. The Director of Environmental Services and the Director of Medical Records will monitor for compliance. |
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 a review of client records and an interview with the facility director, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of three partial hospitalization client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Six client records pertained to the partial hospitalization activity. Four client records were reviewed for documentation of the individual treatment plans. The treatment plan for client record # 16 could not be located to review. Only three treatment plans could be reviewed for type and frequency of services. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of: type and frequency of treatment and rehabilitation services. The facility failed to provide documentation of the type and frequency of treatment and rehabilitation services in client records # 17 and 18.
Client # 17 was admitted into treatment on November 29, 2010. The individual treatment plan was completed on December 1, 2010. The individual treatment and rehabilitation plan did not include the type and frequency of individual and group counseling sessions.
Client # 18 was admitted into treatment on December 1, 2010. The individual treatment plan was completed on December 3, 2010. The individual treatment and rehabilitation plan did not include the type and frequency of individual and group counseling sessions.
The facility director was interviewed on December 20 - 21, 2010 and confirmed that these treatment plans did not include documentation of the type and frequency of individual and group counseling sessions.
This is a repeat citation.
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Plan of Correction
Retraining of all Main Campus Clinical Staff, who write treatment plans, will be completed no later than 1/28/11. The Clinical Managers will complete weekly chart audits to monitor for compliance. The Clinical Manager of Outpatient Services will address deficiencies in clinical supervision until all treatment plans reflect appropriate documentation. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based on a review of client records, the facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in two of three partial hospitalization client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Six client records were from the partial hospitalization activity. Three client records were required to document individual counseling at least twice weekly. Per regulation, counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented: individual counseling, at least twice weekly. The facility failed to document individual counseling, at least twice weekly, in client records # 17 and 18.
Client # 17 was admitted into treatment on November 29, 2010. No individual counseling sessions were documented for the week of November 29, 2010. Only one individual counseling session was documented for the week of December 13, 2010. There was no documentation of any other individual counseling sessions being scheduled or conducted.
Client # 18 was admitted into treatment on December 1, 2010. No individual counseling sessions were documented for the weeks of December 1, 2010 and December 6, 2010. Only one individual counseling session was documented for the week of December 13, 2010. There was no documentation of any other individual counseling sessions being scheduled or conducted.
The facility director was interviewed on December 21, 2010 and confirmed these client records did not contain documentation of two individual counseling sessions per week. The facility director confirmed that the policy is to complete two individual counseling sessions per week in the partial hospitalization activity.
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Plan of Correction
Retraining of all Main Campus Clinical Staff, who work in the Partial Hospital program, will be completed no later than 1/28/11. All staff will be reminded of the regulation that Partial Hospital patients receive 2 (two) individual sessions each week. They will also be reminded that this expectation needs to be documented in type and frequency on the treatment plan. The Clinical Manager will complete weekly chart audits to monitor for compliance. The Clinical Manager of Outpatient Services will address deficiencies in clinical supervision until all patients charts have the appropiate services documented. |
709.28(c)(3) 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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the purpose of disclosure in six of twenty-three client records.
The findings included:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Twenty-three client records were required to include documentation of an informed and voluntary consent to release information from the client; including the purpose of disclosure. Four client records were from a timeframe outside of the current licensing inspection. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record; including the purpose of the disclosure. The facility failed to obtain an informed and voluntary consent from the client; including the purpose of disclosure in client records # 6, 10, 11, 12, 18 and 25.
Client # 6 was admitted into treatment on February 14, 2010 and discharged on February 24, 2010. A consent to release information to a treatment provider, dated February 23, 2010, did not include the purpose of disclosure.
Client # 10 was admitted into treatment on December 7, 2010. A consent to release information to a probation officer, dated December 7, 2010, did not include the purpose of disclosure. Consents to release information to other treatment providers and a probation officer, dated 12/10/10, did not include the purpose of disclosure.
Client # 11 was admitted into treatment on August 23, 2010. A consent to release information to the school, dated August 23, 2010, did not include the purpose of disclosure.
Client # 12 was admitted into treatment on December 7, 2010. Consents to release information to the school and other providers, dated December 7, 2010, did not include the purpose of disclosure.
Client # 18 was admitted into treatment on December 1, 2010. Four consents to release information to other treatment providers, dated December 1, 2010, did not include the purpose of disclosure.
Client # 25 was admitted into treatment on June 28, 2010. A consent to release information to a provider, dated June 23, 2010, did not include the purpose of disclosure.
On December 20 - 21, 2010, the facility director was interviewed. The facility director confirmed the consents to release information in client records # 6, 10, 11, 12, 18 and 25 did not include the purpose of disclosure.
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Plan of Correction
Retraining of all Main Campus Staff, who complete consents, will be completed no later than 1/28/11. The Managers will complete weekly chart audits to monitor for compliance. The Manager of Admissions and Manager of the Admissions Clinical Specialists will address deficiencies in supervision until all consents indicate the purpose of the disclosure on the consent to release information. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in two of two client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Two records were required to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client records # 9 and 15.
In client record # 9, the client was admitted into treatment on October 31, 2010 and was involuntarily terminated from the project on November 3, 2010. There was no documentation of written notification to the client, at the time of the licensing inspection, on December 20 - 21, 2010.
In client record # 15, the client was admitted into treatment on February 1, 2010 and was involuntarily terminated from the project on March 2, 2010. There was no documentation of written notification to the client, at the time of the licensing inspection, on December 20 - 21, 2010.
The facility director was interviewed on December 21, 2010 and confirmed that client records # 9 and 15 did not include a written involuntary termination notice.
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Plan of Correction
Retraining of all Main Campus Clinical Staff, who are involved in involuntary terminations, will be completed no later than 1/28/11. The Clinical Managers will complete weekly chart audits to monitor for compliance. The Clinical Managers of Outpatient Services and Inpatient Services will address deficiencies in clinical supervision until all treatment records reflect appropriate documentation. |
709.63(a)(1) LICENSURE Consent Forms
709.63. 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:
(1) Consent forms.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a follow-up consent form in two of two short-term detoxification client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Four client records pertained to the short-term detoxification activity. Two client records were reviewed for follow-up consents. Per facility policy, follow-up consents will be completed during the intake process. The facility failed to document follow-up consent forms in client records # 1 and 2.
Client # 1 was admitted into treatment on July 31, 2010 and discharged on August 3, 2010. Client record # 1 did not include a consent to follow-up form.
Client # 2 was admitted into treatment on April 21, 2010 and discharged on April 26, 2010. Client record # 2 did not include a consent to follow-up form.
The facility director was interviewed on December 20 - 21, 2010 and confirmed follow-up consents were not included in client records # 1 and 2. The facility director also confirmed the policy is to complete these consent forms during the intake process.
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Plan of Correction
Retraining of all Detox Staff, who complete discharge paperwork, will be completed no later than 1/28/11. The Detox Director will complete weekly chart audits to monitor for compliance. The Director will also address deficiencies in clinical supervision until all patient charts reflect appropriate documentation. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) Follow-up information.
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Observations
Based on a review of the facility's policy and procedure manual, client records and an interview with the facility director, the facility failed to document follow-up information in two of two short-term detoxification client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Four client records pertained to the short-term detoxification activity. Two client records were closed and required documentation of a follow-up. Per agency policy, a follow-up will be conducted within 30 days of discharge. The facility failed to conduct a follow-up within 30 days of discharge in client records # 1 and 2.
Client # 1 was admitted into treatment on July 31, 2010 and discharged on August 3, 2010. This client did not continue treatment in another level of care. Follow-up was due to be completed no later than August 31, 2010. Client record # 1 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 21, 2010.
Client # 2 was admitted into treatment on April 21, 2010 and discharged on April 26, 2010. This client did not continue treatment in another level of care. Follow-up was due to be completed no later than May 26, 2010. Client record # 2 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 21, 2010.
The facility director was interviewed on December 21, 2010 and confirmed documentation of follow-up information could not be located. Follow-ups are conducted by the research department. As of December 21, 2010, the research department did not provide verification of follow-ups on clients # 1 and 2.
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Plan of Correction
All responsible staff will receive training on this issue no later than March 31. Consents will be procured, and the appropriate staff will complete the contact in the time frame required by policy. Appropriate Directors and Managers will monitor for compliance. Deficiencies will be addressed in supervision until all patient charts are in complianmce. |
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 and an interview with the facility director, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of four inpatient client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Eight client records pertained to the inpatient nonhospital activity. Four client records were reviewed for documentation of the individual treatment plans. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of: type and frequency of treatment and rehabilitation services. The facility failed to provide documentation of the type and frequency of treatment and rehabilitation services in client records # 7, 10, 11 and 12.
Client # 7 was admitted into treatment on February 23, 2010 and discharged on March 1, 2010. The individual treatment plan was completed on February 23, 2010. The individual treatment and rehabilitation plan did not include the type and frequency of individual counseling sessions.
Client # 10 was admitted into treatment on December 7, 2010. The individual treatment plan was completed on December 7, 2010. The individual treatment and rehabilitation plan did not include the type and frequency of individual counseling sessions.
Client # 11 was admitted into treatment on August 23, 2010. The individual treatment plan was completed on August 24, 2010. The individual treatment and rehabilitation plan did not include the frequency of individual counseling sessions.
Client # 12 was admitted into treatment on December 7, 2010. The individual treatment plan was completed on December 8, 2010. The individual treatment and rehabilitation plan did not include the frequency of individual counseling sessions.
The facility director was interviewed on December 20 - 21, 2010 and confirmed that these treatment plans did not include documentation of the type and frequency of individual counseling sessions.
This is a repeat citation.
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Plan of Correction
Retraining of all Main Campus Clinical Staff, who write treatment plans, will be completed no later than 1/28/2011. The Clinical Managers will complete weekly chart audits to monitor for compliance. The Clinical Managers of the inpatient programs will address deficiencies in clinical supervision until all patient charts reflect appropriate documentation in all of the treatment palns. |
709.53(a)(1) LICENSURE Consent Forms
709.53. 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:
(1) Consent forms.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a follow-up consent form in three of five inpatient client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Eight client records pertained to the nonhospital inpatient activity. Five client records were reviewed for follow-up consents. Per facility policy, follow-up consents will be completed during the intake process. The facility failed to document follow-up consent forms in client records # 5, 7 and 9.
Client # 5 was admitted into treatment on January 8, 2010 and discharged on January 27, 2010. Client record # 5 did not include a consent to follow-up form.
Client # 7 was admitted into treatment on February 23, 2010 and discharged on March 1, 2010. Client record # 7 did not include a consent to follow-up form.
Client # 9 was admitted into treatment on October 31, 2010 and discharged on November 4, 2010. Client record # 9 did not include a consent to follow-up form.
The facility director was interviewed on December 20 - 21, 2010 and confirmed follow-up consents were not included in client records # 5, 7 and 9. The facility director also confirmed the policy is to complete these consent forms during the intake process.
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Plan of Correction
Retraining of all Main Campus Staff, who are required to complete consents for follow-up, will be completed no later than 3/31/11. The appropriate managers will monitor for compliance. The managers will address deficiencies in supervision until all patient charts contain the appropriate consents. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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, client records and an interview with the facility director, the facility failed to document follow-up information in three of four inpatient client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Eight client records pertained to the nonhospital inpatient activity. Five client records were closed. Four of these closed client records required documentation of a follow-up. One client did not consent to a follow-up. Per agency policy, a follow-up will be conducted within 30 days of discharge. The facility failed to conduct a follow-up within 30 days of discharge in client records # 5, 7 and 9.
Client # 5 was admitted into treatment on January 8, 2010 and discharged on January 27, 2010. Follow-up was due to be completed no later than February 27, 2010. Client record # 5 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 21, 2010.
Client # 7 was admitted into treatment on February 23, 2010 and discharged on March 1, 2010. Follow-up was due to be completed no later than April 1, 2010. Client record # 7 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 21, 2010.
Client # 9 was admitted into treatment on October 31, 2010 and discharged on November 4, 2010. Follow-up was due to be completed no later than December 4, 2010. Client record # 9 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 21, 2010.
The facility director was interviewed on December 21, 2010 and confirmed documentation of follow-up information could not be located. Follow-ups are conducted by the research department. As of December 21, 2010, the research department did not provide verification of follow-ups on clients # 5, 7 and 9.
This is a repeat citation.
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Plan of Correction
All responsible staff will receive training no later than 3/31/11. Consents will be procured, and the appropriate staff will complete the contact in the time frame required by policy. The appropriate Directors and Managers will monitor for compliance. Deficiencies will be addressed in supervision until all patient charts are in 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 and an interview with the facility director, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of six outpatient client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Nine client records pertained to the outpatient activity. Six client records were reviewed for documentation of the individual treatment plans. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of: type and frequency of treatment and rehabilitation services. The facility failed to provide documentation of the type and frequency of treatment and rehabilitation services in client records # 19, 22 and 24.
Client # 19 was admitted into treatment on April 8, 2010 and discharged on June 2, 2010. The individual treatment plan was completed on April 8, 2010. The individual treatment and rehabilitation plan did not include the type and frequency of group counseling sessions or the frequency of individual counseling sessions.
Client # 22 was admitted into treatment on March 1, 2010 and discharged on June 11, 2010. The individual treatment plan was completed on March 1, 2010. The individual treatment and rehabilitation plan did not include the type and frequency of individual counseling sessions.
Client # 24 was admitted into treatment on June 16, 2010. The individual treatment plan was completed on June 16, 2010. The individual treatment and rehabilitation plan did not include the type and frequency of individual counseling sessions.
The facility director was interviewed on December 20 - 21, 2010 and confirmed that these treatment plans did not include documentation of the type and frequency of counseling sessions.
This is a repeat citation.
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Plan of Correction
Retraining of all Main Campus Outpatient Staff will be completed no later than 1/28/11. The Clinical Manager will complete weekly chart audits to monitor for compliance and will address deficiencies in clinical supervision until all patient charts reflect appropriate documentation on all treatment plans. |
709.93(a)(1) 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:
(1) Consent forms.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a follow-up consent form in four of five outpatient client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Nine client records pertained to the outpatient activity. Five client records were reviewed for follow-up consents. Per facility policy, follow-up consents will be completed during the intake process. The facility failed to document follow-up consent forms in client records # 19, 20, 22 and 23.
Client # 19 was admitted into treatment on April 8, 2010 and discharged on June 2, 2010. Client record # 19 did not include a consent to follow-up form.
Client # 20 was admitted into treatment on January 25, 2010 and discharged on March 25, 2010. Client record # 20 did not include a consent to follow-up form.
Client # 22 was admitted into treatment on March 1, 2010 and discharged on June 11, 2010. Client record # 22 did not include a consent to follow-up form.
Client # 23 was admitted into treatment on September 20, 2010 and discharged on November 17, 2010. Client record # 23 did not include a consent to follow-up form.
The facility director was interviewed on December 20 - 21, 2010 and confirmed follow-up consents were not included in client records # 19, 20, 22 and 23. The facility director also confirmed the policy is to complete these consent forms during the intake process.
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Plan of Correction
Retraining of all Main Campus Staff, who are required to complete consents for follow-up, will be completed by 3/31/11. The appropriate Managers and Directors will monitor for compliance. The Managers and Directors will address all deficiencies in supervision until all patient charts contain the appropriate consents. |
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 the facility's policy and procedure manual, client records and an interview with the facility director, the facility failed to document a case consultation in three of five outpatient client records.
The findings include:
Seventeen client records were reviewed on December 17, 2010 and December 20 - 21, 2010. Nine patient records pertained to the outpatient activity. Case consultations were required in five client records. Per regulation, there shall be a complete client record on an individual which includes information relative to the client's involvement with the project and this shall include case consultation notes. The agency policy requires a case consultation to be completed every 90 days. The facility did not document case consultations in client records # 25, 26 and 27.
Client # 25 was admitted into treatment on June 28, 2010. The first case consultation was completed on July 7, 2010. The second case consultation was due to be completed no later than October 7, 2010. There was no documentation of a second case consultation in client record # 25.
Client # 26 was admitted into treatment on September 9, 2010. A case consultation was due to be completed no later than December 9, 2010. There was no documentation of a case consultation in client record # 26.
Client # 27 was admitted into treatment on August 24, 2010. A case consultation was due to be completed no later than November 24, 2010. There was no documentation of a case consultation in client record # 27.
The facility director was interviewed on December 21, 2010 and confirmed these client records did not contain the required case consultations.
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Plan of Correction
Retraining of all Main Campus Outpatient Staff will be completed no later than 1/28/2011. The Clinical Manager will conduct weekly chart audits to monitor for compliance. The Clinical Manager will address defiencies in clinical supervision until all patient charts reflect appropriate documentation of case consultations. |
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, client records and an interview with the facility director, the facility failed to document a follow-up within 30 days of discharge in four of four outpatient client records.
The findings include:
Twenty-seven client records were reviewed on December 17 and December 20 - 21, 2010. Nine client records pertained to the outpatient activity. Five client records were closed. Four client records required documentation of a follow-up. Per agency policy, a follow-up will be conducted within 30 days of discharge. The facility failed to conduct a follow-up within 30 days of discharge in client records # 19, 20, 21 and 22.
Client # 19 was admitted into treatment on April 8, 2010 and discharged on June 2, 2010. Follow-up was due to be completed no later than July 2, 2010. Client record # 19 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 21, 2010.
Client # 20 was admitted into treatment on January 25, 2010 and discharged on March 25, 2010. Follow-up was due to be completed no later than April 25, 2010. Client record # 20 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 21, 2010.
Client # 21 was admitted into treatment on February 15, 2010 and discharged on April 30, 2010. Follow-up was due to be completed no later than May 30, 2010. Follow-up was not completed until September 9, 2010.
Client # 22 was admitted into treatment on March 1, 2010 and discharged on June 11, 2010. Follow-up was due to be completed no later than July 11, 2010. Client record # 22 did not include documentation of a follow-up. Verification of follow-up information was not provided as of the date of this licensing inspection on December 21, 2010.
The facility director was interviewed on December 21, 2010 and confirmed documentation of follow-up information could not be located. Follow-ups are conducted by the research department. As of December 21, 2010, the research department did not provide verification of follow-ups on clients # 19, 20 and 22. The facility director did confirm that client # 21 did not receive a follow-up with 30 days, as required by policy.
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Plan of Correction
All responsible staff will receive training no later than 3/31/2011. Consents will be procured and the appropriate staff will complete the contact in the time frame required by policy. The appropriate Managers and Directors will monitor for compliance. Defiencies will be addressed in supervision until all patient charts are in compliance. |