INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 26, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center-Mount Pleasant 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
The faclility failed to document the clinical supervisor's monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in one of one personnel record reviewed on October 26, 2017.
Employee # 3 was promoted to a clinical supervisor on July 17, 2017. There were no documented supervision notes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 will begin receiving weekly supervision sessions on 10/30/17 and will conclude on 4/30/18.
In these sessions, the facility director will review Employee #3's duties and performance, and will work on the development of supervision skills.
Supervision notes will be written and signed by both individuals. These notes will be retained in a secure file. The HR director will ensure that both the facility director and Employee #3 are maintaining the sessions as scheduled.
If and when a new facility director is hired, the current facility director will educate the new director on the supervision requirement for any new clinical supervisors hired. If a new supervisor is hired, the sessions will be calendarized immediately upon hire date to ensure that the new employee's supervision is timely and in accordance with regulations. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative for fire drill logs reviewed on October 26, 2017.
The fire drill logs were reviewed from October 2016 to September 2017. Fire drills conducted on January 16, May 20, and July 22, 2017 did not document the information documented above.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Although the facility evacuates according to drills conducted by the hospital in which it is housed, further investigation concluded that the drills run by the hospital were not logged into the reporting system.
We determined that the fire drills are a part of routine health and safety on the unit and assigned the responsibility of monitoring and overseeing the documentation of fire drills to the nursing supervisor.
The facility director coordinated a training with our compliance specialist and the nurse supervisor on the organization's reporting system (D3)to ensure that each report includes: the amount of time it took for evacuation; the exit route used; the number of persons in the facility at the time of the drill; problems encountered; and whether the fire alarm or smoke detector was operative.
The nurse supervisor will monitor D3 weekly and will submit monthly a report of her findings to the facility director. |
709.28 (c) 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.
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Observations
The facility failed to obtain an informed and voluntary consent to the funding source for the disclosure of client information in eleven of eleven client records reviewed on October 26, 2017.
Releases of information to the funding source failed to include the name/agency/organization to whom the information would be disclosed in client records # 1, 4, 5, 9, 10 and 11.
Releases of information failed to include the information to be released in client records # 1 and 2.
There was no release of information documented for the funding source in client record # 2.
The facility failed to document compliance with Pa Code 255.5. The facility documents on the Assignment of Benefits form that the facility's President/Chief Executive Officer has the authority to approve the release of additional information to the insurance company if necessary to process claims. This is incorrect; the information released to the funding source is limited to the information outlined in Pa Code 255.5. This statement was documented in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The release of information to an insurance company shall specify the insurance company and limit the release of information to the following:
Whether the client is or is not in treatment; The prognosis of the patient; the nature of the project; a brief description of the progress of the patient; a short statement as to whether the patient has relapsed into drug and alcohol abuse and the frequency of such relapse.
The Director of Health Information Management educated all applicable staff to this revision through electronic communication on November 1, 2017
The Director of Health Information Management will conduct admission chart audits (after each client admission) to ensure compliance with the Consent for Insurance and, in turn will share audit results with Program Directors.
In turn, the Director of Health Information Management educated all applicable staff to this revision through electronic communication also on November 1, 2017
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document that clients were informed of all the required client rights in eleven of eleven client records.
Three client handbooks (Residential, Youth and Outpatient) were reviewed on October 11-13, 2017. Client records were reviewed on October 26, 2017. The clients sign a form acknowledging the receipt of the handbook. None of the three handbooks presented contained all of the required client rights
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All handbooks were and will be reviewed by program Directors and modified to ensure proper documentation of client rights according to DDAP regulation 709.30. For the handbooks that were previously printed, the Director of each program and/or location will ensure that each hand book has an addendum with the updated client rights. Addendums were printed and distributed to program Directors/Managers November 15, 2017.
The "Patient Treatment Agreement" form already exists and provides a signed acknowledgement of receipt of the patient handbook.
As directed by the Program Director, the facility's Admissions Officers/ Assistants will order the printed patient handbook as supplies are needed and will ensure that the correct version of the patient rights is included in the handbook. |