INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 4-8 and January 11-12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center 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 12, 2010.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to provide documentation of HIV/AIDS and TB/STD training in nine of eighteen personnel records.
The findings include:
Twenty three personnel records were reviewed on January 4-8, 2010. An interview with the facility director occurred on January 11 and 12, 2010. Eighteen personnel records were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training in personnel records # 4, 9, 11, 13, 14, 15, 18, 19 and 21.
In personnel record # 4, the staff was hired on June 26, 2006. TB/STD training was due to be completed by June 26, 2007. The facility failed to provide documentation of TB/STD training as of January 12, 2010.
In personnel record # 9, the staff was hired on March 24, 2008. TB/STD training was due to be completed by March 24, 2009. The facility failed to provide documentation of TB/STD training as of January 12, 2010.
In personnel record # 11, the staff was hired on April 16, 2007. TB/STD and HIV/AIDS training were due to be completed by April 16, 2008. The facility failed to provide documentation of TB/STD and HIV/AIDS training as of January 12, 2010.
In personnel record # 13, the staff was hired on June 11, 2007. HIV/AIDS training was due to be completed by June 11, 2008. The facility failed to provide documentation of HIV/AIDS training as of January 12, 2010.
In personnel record # 14, the staff was hired on October 8, 2007. TB/STD training was due to be completed by October 8, 2008. The facility failed to provide documentation of TB/STD training as of January 12, 2010.
In personnel record # 15, the support staff was hired on August 15, 2005. TB/STD and HIV/AIDS training were due to be completed by August 15, 2007. The facility failed to provide documentation of TB/STD and HIV/AIDS training as of January 12, 2010.
In personnel record # 18, the staff was hired on August 11, 1990. TB/STD and HIV/AIDS training were due to be completed by August 11, 1991. The facility failed to provide documentation of TB/STD and HIV/AIDS training as of January 12, 2010.
In personnel record # 19, the support staff was hired on July 2, 2007. TB/STD training was due to be completed by July 2, 2009. The facility failed to provide documentation of TB/STD training as of January 12, 2010.
In personnel record # 21, the staff was hired on January 14, 2008. TB/STD training was due to be completed by January 14, 2009. The facility failed to provide documentation of TB/STD training as of January 12, 2010.
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Plan of Correction
Individual staff who were out of compliance for HIV/AIDS and/or TB/STD training have been scheduled and will be required to attend the training no later than 5/28/2010. Clinical Managers and Supervisors will monitor for compliance.
The Vice-President of Human Resources and Human Resources Director will educate all Directors, Managers and Supervisors on the importance of requiring all Gateway staff to attend Department of Health mandated trainings within the required timeframe. They will also monitor training calendars and training files to insure compliance. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type of services in the individual treatment and rehabilitation plan in four of four client records.
The findings include:
Nineteen client records were reviewed on January 11-12, 2010. Four client records were reviewed as partial hospitalization client records. Documentation of the type and frequency of treatment services was required on the individual treatment and rehabilitation plan in four partial hospitalization client records. The facility did not document the type of services on the individual treatment and rehabilitation plan in client records # 10, 11, 12 and 13.
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Plan of Correction
Retraining of all Main Campus Clincal Staff, who write treatment plans, will take place during the month of February. All training will be be completed no later than Feb 26, 2010. The Clinical Managers will complete weekly chart audits to monitor for compliance and will address counselors in clinical supervision until all of the treatment plans reflect accurately the type of service being provided |
709.83(a)(10) 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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document a discharge summary, completed within 7 days of discharge, in two of three client records.
The findings include:
Nineteen client records were reviewed on January 11-12, 2010. Four client records were reviewed as partial hospitalization records. A discharge summary was required in three partial hospitalization client records. The facility did not document that a discharge summary was completed within 7 days of discharge in client records # 11 and 12.
In client record # 11, the client was discharged on July 3, 2009. The discharge summary was completed on August 12, 2009.
In client record # 12, the client was discharged on June 22, 2009. The discharge summary was completed on July 9, 2009.
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Plan of Correction
Retraining of all Main Campus Clincal Staff will take place during the month of February. All training will be be completed no later than Feb 26, 2010. The Clinical Manager will complete weekly chart audits to monitor for compliance and will address counselors in clinical supervision until all of the discharge summaries are completed within 7 days of discharge. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type and frequency of services on the individual treatment and rehabilitation plan in two of three client records.
The findings include:
Nineteen client records were reviewed on January 11-12, 2010. Four client records were reviewed as inpatient client records. Documentation of the type and frequency of services was required on the individual treatment and rehabilitation plan in three inpatient client records. The facility did not document the type and frequency of services in the individual treatment and rehabilitation plan in client records # 7 and 9.
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Plan of Correction
Retraining of all Main Campus Clincal Staff, who write treatment plans, will take place during the month of February. All training will be be completed no later than Feb 26, 2010. The Clinical Managers will complete weekly chart audits to monitor for compliance and will address counselors in clinical supervision until all of the treatment plans reflect accurately the type and frequency of services being provided |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document a discharge summary, completed within 7 days of discharge, in one of two client records.
The findings include:
Nineteen client records were reviewed on January 11-12, 2010. Four client records were reviewed as inpatient records. A discharge summary was required in two inpatient client records. The facility did not document that a discharge summary was completed within 7 days of discharge in client record #7. The client was discharged on April 8, 2009. The discharge summary was completed on May 25, 2009.
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Plan of Correction
Retraining of all Main Campus Clincal Staff will take place during the month of February. All training will be be completed no later than Feb 26, 2010. The Clinical Managers will complete weekly chart audits to monitor for compliance and will address counselors in clinical supervision until all of the discharge summaries are completed within 7 days of discharge. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 the review of client records and an interview with the facility director, the facility failed to document follow up according to policy in two of two client records.
The findings include:
Nineteen client records were reviewed on January 11-12, 2010. Four client records were reviewed as inpatient records. Follow up was required in two inpatient client records. The facility's follow up policy states that follow up will occur at 1, 3, 6 and 12 months after discharge. The facility did not document follow up according to policy in client records # 6 and 7.
Client # 6 was discharged on May 4, 2009. There was no documentation that a follow up had been conducted on the client since his date of discharge.
Client # 7 was discharged on April 8, 2009. There was no documentation that a follow up had been conducted on the client since her date of discharge.
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Plan of Correction
Gateway is currently in the process of updating it's follow-up policy. Until that is completed, the Director of Research and Evaluation will monitor the follow-up process more closely to assure that it is being completed as stated in our policy. The Senior Director - Main Campus will also meet with the Director of Research and Evaluation to develop a system that will foolproof the follow-up process for main campus patients no later than March 31, 2010. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document the type of services on the individual treatment and rehabilitation plan in three of six client records.
The findings include:
Nineteen client records were reviewed on January 11-12, 2010. Six client records were reviewed as outpatient client records. Documentation of the type of services was required in the individual treatment and rehabilitation plan in six outpatient client records. The facility did not document the type of services on the individual treatment and rehabilitation plan in client records # 15, 17 and 18.
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Plan of Correction
Retraining of all Main Campus Clincal Staff, who write treatment plans, will take place during the month of February. All training will be be completed no later than Feb 26, 2010. The Clinical Manager will complete weekly chart audits to monitor for compliance and will address counselors in clinical supervision until all of the treatment plans reflect accurately the type of services being provided |
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 the review of client records and an interview with the facility director, the facility failed to document follow up according to policy in two of four client records.
The findings include:
Nineteen client records were reviewed on January 11-12, 2010. Six client records were reviewed as outpatient client records. Follow up was required in four outpatient client records. The facility's follow up policy states that follow up will occur at 1, 3, 6 and 12 months after discharge. The facility did not document follow up according to policy in client records # 14 and 16.
Client # 14 was discharged on November 30, 2009. There was no documentation that a follow up had been conducted as of 1 month after the client's discharge.
Client # 16 was discharged on June 23, 2009. There was no documentation that a follow up had been conducted on the client since her date of discharge.
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Plan of Correction
Gateway is currently in the process of updating it's follow-up policy. Until that is completed, the Director of Research and Evaluation will monitor the follow-up process more closely to assure that it is being completed as stated in our policy. The Senior Director - Main Campus will also meet with the Director of Research and Evaluation to develop a system that will foolproof the follow-up process for main campus patients no later than March 31, 2010. |