INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17-18th, 2018 of Gateway/Greentree by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
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Plan of Correction
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
A review of the October 2017 through August 2018 fire drill logs was conducted during the onsite inspection. The facility failed to conduct drills on different days of the weeks, as 10 of the 11 drills were done on the last day of the month.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills were not performed throughout the month. Manager will perform fire drills consistently throughout the month and not only on the last day.
The director of outpatient services will monitor monthly completion of fire drills.
This deficiency will be corrected immediately. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The Facility failed to document an annual written individual staff performance evaluation for staff in employee #1's employee record.
Employee #1 was hired 5/2/2000 and still employeed as project director at the time of the inspection. Employee #1's record failed to contain an annual proformance review for 2017.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
All Vice Presidents will receive a yearly PE in October.
The VP of human resources will monitor completion of yearly PEs.
This deficiency will be corrected by October 31, 2018. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to document treatment plan updates within the regulatory timeframe in 4 client records reviewed.
Client #1 was admitted on 6/21/2017 and was still active at the time of the inspection. A treatment plan update was completed on 8/29/2017 and the next update was due no later than 10/29/2017 however, there was no update documented in the record until 4/17/18.
Client #2 was admitted on 6/25/2018 and was still active at the time of the inspection. A treatment plan update was completed on 6/28/18 and the next update was due no later than 8/28/2018 ; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on 5/31/2018 and was discharged on 9/14/2018. A treatment plan update was completed on 6/5/2018 and the next update was due no later than 8/5/2018; however, there was no update documented in the record until 9/14/2018.
Client #8 was admitted on 7/25/2017 and was discharged on 8/15/2018. A treatment plan update was completed on 12/19/2017 and the next update was due no later than 2/19/2018; however, there was no update documented in the record unitil 6/19/2018.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Four patient treatment plans were not updated in a timely manner.
The manager will immediately reeducate all staff at Greentree as to the parameters of required updates, so ensure all treatment plans are updated in a timely manner. The manager will monitor treatment plan updates with a monthly audit to review at least 50% of all required treatment plan updates.
The staff will be educated by October 31, 2018 and the treatment plan audit will be implemented immediately. |