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 January 10, 2011 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 3, 2011.
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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 a review of personnel training records and staff interviews, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of two personnel training records.
The findings include:
Eleven personnel training records were reviewed on December 13, 2010 and January 11, 2011. Two personnel training records pertained to counselors. Two personnel training records required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel training record # 10.
Employee # 10 was hired, for the position of counselor, on March 17, 2008. The facility training year is from January through December. Employee # 10 only completed 9.5 clock hours of annual training from January 2010 through December 2010.
The human resources director was interviewed on December 15, 2010 and confirmed that employee record # 10 did not include 25 clock hours of annual training. The clinical supervisor was interviewed on January 10, 2011. The clinical supervisor confirmed employee # 10 had not provided documentation of 25 clock hours of annual training for 2010.
This is a repeat citation.
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Plan of Correction
The Director and Clinical Manager have completed this year's staff training plans.
The Clinical Manager has been instructed to ensure the scheduling and monitoring of all facility staff trainings including the clerical support staff. She will follow the established procedures, which are noted below:
- To ensure closer monitoring of staff trainings, the Clinical Manager will create an on-site file for each staff member, including all support staff, which will include copies of training plans & training records/certificates.
- The Manager will review these records at the end of each quarter as an aid to assist staff in scheduling and completing the trainings listed on their annual plans, including required/mandatory trainings. In turn, the Manager will present a quarterly status report to the Director.
- The Manager will compare these records with HR every 6 months to ensure completeness of both files. This will assist the manager to maintain a more hands-on record of the needed trainings for each staff (both clinical and clerical).
These on-site files on all staff will be constructed by February 11, 2011 and will be maintained by the Clinical Manager thereafter.
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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 procedures, client records and an interview with the clinical supervisor, the facility failed to document the completion of a 30 day follow-up in three of three partial hospitalization client records.
The findings include:
Eighteen client records were reviewed on December 17, 2010 and January 10, 2011. Seven client records pertained to the partial hospitalization activity. Three client records were closed and required documentation of a follow-up. Per facility 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, 2 and 3.
Client # 1 was admitted into treatment on June 23, 2010 and discharged on July 1, 2010. Follow-up was due to be completed no later than August 1, 2010. Follow-up was not completed until August 30, 2010.
Client # 2 was admitted into treatment on January 11, 2010 and discharged on January 22, 2010. Follow-up was due to be completed no later than February 22, 2010. Follow-up was not completed until March 24, 2010.
Client # 3 was admitted into treatment on April 16, 2010 and discharged on April 30, 2010. Follow-up on the client was due to be completed no later than May 30, 2010. Verification of follow-up documentation was not available at the time of the licensing inspection on January 10, 2011.
The clinical supervisor was interviewed on January 10, 2011. Follow-ups are conducted by the research department. The clinical supervisor confirmed the follow-ups were not conducted according to the 30 day follow-up policy in client records # 1, 2 and 3. As of January 10, 2011, the research department had not provided follow-up documentation for client record # 3.
This is a repeat citation.
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Plan of Correction
The Program Director will assist the VP of Therapy programs to revise the policy and procedures (P & Ps) relative to follow-up contacts with discharged patients.
The new policy will include that Gateway's satellite facilities will attempt telephone follow-up contacts for their respective discharged patients by no more than 6 months after patient discharges. This will ensure that each satellite facility will be responsible for follow-up contacts and the related documentation and that this will occur before the closed patient charts are submitted to the medical records department for storage.
Once the new P & Ps are approved by administration, each satellite facility will conduct staff training on the new P & Ps, which will be implemented by February 28, 2011.
The director will assign the administrative assistant to ensure that the follow-up contacts will be conducted as assigned. The administrative assistant will report the results of the follow-up contacts on, at least, a bi-monthly basis to the director.
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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 clinical supervisor, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of two client records.
The findings include:
Eighteen client records were reviewed on December 17, 2010 and January 10, 2011. 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 record # 3.
In client record # 3, the client was admitted into treatment on April 16, 2010 and was involuntarily terminated from the project on April 30, 2010. There was no documentation of written notification to the client, at the time of the licensing inspection, on December 17, 2010 and January 11, 2011.
The clinical supervisor was interviewed on January 11, 2011. The clinical supervisor contacted the medical records department and received verification that an involuntary termination notice was not included in client record # 3.
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Plan of Correction
On January 18, 2011, the Clinical Manager conducted a staff inservice training on involuntary discharges. The training reviewed the following procedures:
- Clinical staff will consult with the clinical manager any time an involuntary discharge of a patient is being considered. (The primary goal of this consultation is to collaborate on possible interventions to retain the patient in treatment and/or to consider a more appropriate treatment modality for the patient's care.)
- If an involuntary discharge is then still considered, the clinical manager will inform the program director of the details of the patient case and the discharge decision.
- In turn, if this type of discharged is agreed on, the clinical manager will ensure that written notification of the discharge, the reason(s) for the discharge and the patient's appeal procedures are presented to the patient in writing .
- This documentation will also be copied and included in the medical record chart.
- At the time of patient discharge, the clinical manager will conduct a chart audit on the patient's chart and will ensure that this necessary informed documentation has occurred and has been copied to the patient chart.
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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 procedures, client records and an interview with the clinical supervisor, the facility failed to document the completion of a 30 day follow-up in four of four outpatient client records.
The findings include:
Eighteen client records were reviewed on December 17, 2010 and January 10, 2011. Ten client records pertained to the outpatient activity. Four client records were closed and required documentation of a follow-up. Per facility 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 # 8, 9, 10 and 11.
Client # 8 was admitted into treatment on August 5, 2010 and discharged on November 15, 2010. Follow-up on the client was due to be completed no later than December 15, 2010. Verification of follow-up documentation was not available at the time of the licensing inspection on January 10, 2011.
Client # 9 was admitted into treatment on July 19, 2010 and discharged on September 23, 2010. Follow-up was due to be completed no later than October 23, 2010. Follow-up was not completed until November 23, 2010.
Client # 10 was admitted into treatment on April 5, 2010 and discharged on May 17, 2010. Follow-up was due to be completed no later than June 17, 2010. Follow-up was not completed until August 3, 2010.
Client # 11 was admitted into treatment on March 22, 2010 and discharged on April 19, 2010. Follow-up on the client was due to be completed no later than May 19, 2010. Verification of follow-up documentation was not available at the time of the licensing inspection on January 10, 2011.
The clinical supervisor was interviewed on January 10, 2011. Follow-ups are conducted by the research department. The clinical supervisor confirmed the follow-ups were not conducted according to the 30 day follow-up policy in client records # 8, 9, 10 and 11. As of January 10, 2011, the research department had not provided follow-up documentation for client records # 8 and 11.
This is a repeat citation.
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Plan of Correction
The Program Director will assist the VP of Therapy programs to revise the policy and procedures (P & Ps) relative to follow-up contacts with discharged patients.
The new policy will include that Gateway's satellite facilities will attempt telephone follow-up contacts for their respective discharged patients by no more than 6 months after patient discharges. This will ensure that each satellite facility will be responsible for follow-up contacts and the related documentation and that this will occur before the closed patient charts are submitted to the medical records department for storage.
Once the new P & Ps are approved by administration, each satellite facility will conduct staff training on the new P & Ps, which will be implemented by February 28, 2011.
The director will assign the administrative assistant to ensure that the follow-up contacts will be conducted as assigned. The administrative assistant will report the results of the follow-up contacts on, at least, a bi-monthly basis to the director.
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