INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on January 24, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel training records, the facility failed to document individual training plans by December of each year, as per facility policy, in four of four personnel records.
The findings include:
Eleven personnel training records were reviewed on January 3 - 5, 2012. Two of the training records reviewed pertained to new employees and their training plan was completed in the middle of the facility training year and four records were that of interns. Per facility policy, training plans will be completed by the end of each year in December. The facility's training year is from January through December. Training plans were reviewed for the 2011 training year and were due to be completed no later than December 31, 2010.
The facility failed to document individual training plans by December 31, 2010 in personnel training records # 1, 2, 3 and 4. Training plans for these employees were completed between January 25 and February 1, 2011.
The facility director and human resources director were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
As a result of the recent licensing visit, Gateway Rehab's Policy and Procedure for Staff Training and Development was changed. The new P & P states that training year will be from February 1 to January 31. Therefore the 2012 - 2013 training year begin February 1, 2012 and ends January 31, 2013.
The change also specifically states that supervisory staff will develop an annual training plan for each of the employees in their department. The calendar includes individual training needs, the topics and number of hours of training required by various outside sources, licensing and regulatory groups, and internal and external training events. The Human Resources staff will assist the supervisors in the development of these training calendars.
The 2012 calendars were forwarded to the supervisory staff on 1/23/2012 and are due by 2/1/2012.
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709.83(a)(6) 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of one successfully discharged client records.
The findings include:
Eight partial hospitalization client records were reviewed on January 6, 9 and 24, 2012. One client was successfully discharged and required the completion of an aftercare plan. There was no documentation of an aftercare plan in client record # 1.
Client #1 was admitted to treatment on December 6, 2010 and was successfully discharged on February 18, 2011. There was no documentation of an aftercare plan in client record #1.
Interviews with the facility director and clinical supervisor took place at various times throughout the licensing inspection. It was confirmed that no aftercare plan was documented in client record #1.
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Plan of Correction
On February 6 , 2012, the Clinical Manager, conducted a staff meeting with clinical staff, which included a review of the regulatory standard and facility's policy on aftercare plans.
This review instructed staff to complete an aftercare plan with all patients that have completed the prescribed treatment plans and related treatment activities; and that the aftercare plans will not only be written, but also signed and dated by the patient and a staff member.
The Clinical Manager will include this documentation in her monthly patient chart audits to ensure that they are consistently being done.
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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 procedure manual and client records, the facility failed to document follow-up information in one of one partial hospitalization client records.
The findings include:
Eight partial hospitalization client records were reviewed on January 6, 9 & 24, 2012. Four client records were closed. One of the closed client records required documentation of a follow-up attempt. Per agency policy, a follow-up will be conducted within six months of discharge. The facility failed to conduct a follow-up within six months of discharge in client record # 3.
Client # 3 was admitted into treatment on June 6, 2011 and discharged on June 8, 2011. A follow-up attempt was due to be completed no later than December 8, 2011. The facility failed to provide documentation of a follow-up attempt as of January 24, 2012.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the December 28, 2010 licensing inspection.
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Plan of Correction
As of 2/6/2012, the admissions staff at all levels of care will complete the consent for follow-up contacts with every patient that is admitted.
Regarding transfers from to any satellite facility, these consents will again be completed upon admission to the satellite, before the hard copy medical record chart arrives at that site, to ensure that a completed consent will be included in each patient's medical record.
With completed consent forms available in each patient's medical record, the staff assigned to make follow-up calls/attempts will be able to do so. These contacts/attempts will be conducted within 6 months of the patient's discharge from the final level of care of the patient's complete treatment event.
On February 6, 2012, the Director of Outpatient Services, reviewed the procedures for follow-up conctacts with the facility's administrative assistant and clinical manager. This review underscored the need for the assigned facility staff to conduct follow-up attempts and complete the required documentation, entering it into the medical record chart. |
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, the facility failed to document probationary and annual work performance evaluations which included individual staff performance in three of six personnel records.
The findings include:
Eleven personnel records were reviewed on January 3-5, 2012. Six personnel records were required to include documentation of annual performance evaluations. There were no annual performance evaluations documented in personnel records #4, 5 and 6.
Employee #4 was hired at this facility on July 1, 2006. The last annual performance evaluation documented in personnel record #4 was completed on January 16, 2009.
Employee #5 was hired at this facility on May 9, 2011. A probationary evaluation was due to be completed on November 9, 2011. There was no performance evaluation documented in the personnel record of employee #5.
Employee #6 was hired at this facility on May 2, 2011. A probationary evaluation was due to be completed on November 2, 2011. There was no performance evaluation documented in the personnel record of employee #6.
Interviews were conducted with human resources personnel, the facility director and clinical supervisor throughout the licensing inspection. Documentation of the performance evaluations were not provided and could not be located.
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Plan of Correction
Although it is the practice of the Human Resources Department to inform the agency managers of up-coming performance evaluations that are due, beginning with February, 2012, this facility's Clinical Manager will develop her own monthly tickler-file system, which will remind her of all six month and annual performance evaluations that are due.
In turn, she will complete all performance evaluations during the month they are due. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of one successfully discharged client records.
The findings include:
Seven outpatient client records were reviewed on January 6, 9 and 24, 2012. Three clients were successfully discharged and required the completion of an aftercare plan. There was no documentation of an aftercare plan in client records # 10, 11 and 15.
Client #10 was admitted to treatment on March 9, 2011 and was successfully discharged on June 3, 2011. There was no documentation of an aftercare plan in client record #10.
Client #11 was admitted to treatment on March 7, 2011 and was successfully discharged on June 10, 2011. There was no documentation of an aftercare plan in client record #11.
Client #15 was admitted to treatment on March 14, 2011 and was successfully discharged on December 19, 2011. There was no documentation of an aftercare plan in client record #15.
Interviews with the facility director and clinical supervisor took place at various times throughout the licensing inspection. It was confirmed that no aftercare plan was documented in client records #10, 11 and 15.
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Plan of Correction
On February 6 , 2012, the Clinical Manager, conducted a staff meeting with clinical staff, which included a review of the regulatory standard and facility's policy on aftercare plans.
This review instructed staff to complete an aftercare plan with all patients that have completed the prescribed treatment plans and related treatment activities; and that the aftercare plans will not only be written, but also signed and dated by the patient and a staff member.
The Clinical Manager will include this documentation in h/her monthly patient chart audits to ensure that they are consistently being done.
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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 procedure manual and client records, the facility failed to document follow-up information in two of two outpatient client records.
The findings include:
Seven outpatient client records were reviewed on January 6, 9 & 24, 2012. Four client records were closed. Two of the closed client records required documentation of a follow-up attempt. Per agency policy, a follow-up will be conducted within six months of discharge. The facility failed to conduct a follow-up within six months of discharge in client record # 10 and 11.
Client # 10 was admitted into treatment on March 9, 2011 and discharged on June 3, 2011. A follow-up attempt was due to be completed no later than December 3, 2011. The facility failed to provide documentation of a follow-up attempt as of January 24, 2012.
Client # 11 was admitted into treatment on March 7, 2011 and discharged on June 10, 2011. A follow-up attempt was due to be completed no later than December 10, 2011. The facility failed to provide documentation of a follow-up attempt as of January 24, 2012.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the December 28, 2010 licensing inspection.
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Plan of Correction
As of 2/6/2012, the admissions staff at all levels of care will complete the consent for follow-up contacts with every patient that is admitted.
Regarding transfers from to any satellite facility, these consents will again be completed upon admission to the satellite, before the hard copy medical record chart arrives at that site, to ensure that a completed consent will be included in each patient's medical record.
With completed consent forms available in each patient's medical record, the staff assigned to make follow-up calls/attempts will be able to do so. These contacts/attempts will be conducted within 6 months of the patient's discharge from the final level of care of the patient's complete treatment event.
On February 6, 2012, the Director of Outpatient Services, reviewed the procedures for follow-up contacts with the facility's administrative assistant and clinical manager. This review underscored the need for the assigned facility staff to conduct follow-up attempts and complete the required documentation on all discharged patients, entering it into their medical record charts.
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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the staffing requirements facility summary report and active client list, the facility exceed the authorized capacity for the partial hospitalization activity.
The findings include:
The staffing requirements facility summary report was reviewed on January 24, 2012. The summary report, signed by the Project/Facility Director, indicated the facility had 20 current clients in the partial hospitalization activity. The facility is licensed by the Division for a maximum client capacity of 10.
The Facility Director generated an active client list on January 24, 2012. The active client list had 20 current clients.
An interview with the facility director took place on January 24, 2012. It was confirmed that the current census for the partial hospitalization activity was 20 and the approved capacity was 10.
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Plan of Correction
The Vice President of Therapy Programs has requested an increase in the facility's environment capacities.
By February 17, 2012, a letter was written to the Dept of Health, Division of Licensing, to increase the capacity of Partial Hospitalization to 40.
Additionally, the facility will not ever exceed the licensed capacity. |