INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gateway Greensburg 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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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
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of four applicable records reviewed.
Client #4 was admitted on July 22, 2022 and was active at the time of the inspection. A comprehensive treatment plan was completed on July 25, 2022 and the next update was due no later than September 25, 2022; however, the next update was not completed at the time of the inspection.
Client #6 was admitted on March 24, 2022 and discharged on May 27, 2022. A comprehensive treatment plan was completed on March 25, 2022 and the next update was due no later than May 25, 2022; however, there was no documentation one was completed in the record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical OP Director will immediately re-educate all staff at Greensburg as to the parameters of the required Treatment Plan updates, to ensure all treatment plans are updated in a timely manner.
The OP 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 November 30, 2022 and the treatment plan audit will be implemented December 1, 2022. |
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 client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of one applicable record reviewed.
Client #6 was admitted on March 24, 2022 and discharged on May 27, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical OP Director will immediately re-educate the OP Manager and Administrative Assistant at Allegheny Valley as to the parameters of the required follow-up regulation.
The OP Manager will monitor the consent for follow-up for all new admissions monthly to ensure that the Administrative Assistant knows which patients have consented for follow-up. The Administrative Assistant will track when the follow-up calls/letters need to be completed per the GRC policy. The OP Manager will conduct a monthly audit to ensure that the follow-up calls/letters are completed.
The OP Manager and Administrative Assistant will be educated by November 30, 2022, and the follow-up consent audit will begin December 1, 2022. The follow-up calls/letters audit will begin January 2, 2023. |