INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 22 - 23, 2013 by staff from the Division of Drug and Alcohol Program Licensure. 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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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 a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in four of four partial hospitalization client records.
The findings include:
Eight partial hospitalization client records were reviewed on January 7 and January 22, 2013. Four client records were reviewed for the type and frequency of treatment services in the individual treatment plan. The facility failed to document the type and frequency of individual counseling sessions in client records # 5. The facility failed to document the frequency of individual counseling sessions in client records # 6, 7 and 8.
Client # 5 was admitted into treatment on November 7, 2012. The individual treatment plan was completed on November 12, 2012. The client is participating in group and individual counseling. The facility failed to document the type and frequency of individual counseling sessions in the treatment plan of client # 5.
Client # 6 was admitted into treatment on January 14, 2013. The individual treatment plan was completed on January 10, 2013. The client is participating in group and individual counseling. The client is required to attend two individual counseling sessions per week. The facility failed to document the frequency of these individual counseling sessions in the treatment plan of client # 6.
Client # 7 was admitted into treatment on November 8, 2012. The individual treatment plan was completed on November 8, 2012. The client is participating in group and individual counseling. The client is required to attend two individual counseling sessions per week. The facility failed to document the frequency of these individual counseling sessions in the treatment plan of client # 7.
Client # 8 was admitted into treatment on December 17, 2012. The individual treatment plan was completed on December 19, 2012. The client is participating in group and individual counseling. The client is required to attend two individual counseling sessions per week. The facility failed to document the frequency of these individual counseling sessions in the treatment plan of client # 8.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Clinical Manager conducted and in-service on treatment plans during two consecutive staff meetings (Jan. 29 and Feb 5, 2013). As part of the in-service the manager reviewed the regulatory standards and this citation with the staff. Type and frequency of services was one focus of review. Staff members are to specifically write the type and frequency of services as the first action step of each treatment plan. Written plans for all levels of care were exemplified for staff.
Also the Clinical Manager will review and sign all treatment plans and will now ensure that the appropriate and required type and frequency of services are written in each plan before final saved in the electronic medical record.
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709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in three of three partial hospitalization client records.
The findings include:
Eight partial hospitalization client records were reviewed on January 7 and January 22, 2013. Three client records were reviewed for documentation of treatment plan updates and were required to include an assessment of the client's progress in relationship to the stated goals. The facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in client records # 5, 7 and 8.
Client # 5 was admitted into treatment on November 7, 2012. The comprehensive treatment plan was completed on November 12, 2012. Treatment plan updates were completed on December 13, 2012 and January 14, 2013 and did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 7 was admitted into treatment on November 8, 2012. The comprehensive treatment plan was completed on November 8, 2012. A treatment plan update was completed on December 7, 2012 and did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 8 was admitted into treatment on December 17, 2012. The comprehensive treatment plan was completed on December 19, 2012. A treatment plan update was completed on January 7, 2013 and did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
On 2/5/13, the Clinical Manager conducted an in-service session with the clinical staff and demonstrated how they can more completely document treatment plan updates in the agency's new EMR. The treatment plan review document is constructed whereby staff can document "notes" associated with each objective in the plan.
The Manager will review and electronically sign each treatment plan and review and will ensure that the clients' progress or lack of progress on the stated goals and objectives are included and before final saving the document.
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document an individualized treatment and rehabilitation plan in two of seven outpatient client records.
The findings include:
Eleven outpatient client records were reviewed on January 7 and January 22 - 23, 2012. Seven client records were reviewed for individualized treatment and rehabilitation plans. The treatment and rehabilitation plans for clients # 13 and 14 were identical and were not individualized.
Client # 13 was admitted into treatment on July 10, 2012. The treatment plan was completed on September 17, 2012. The treatment plan was not individualized and included identical goals and objectives as the treatment plan completed for client # 14.
Client # 14 was admitted into treatment on July 26, 2012. The treatment plan was completed on July 26, 2012. The treatment plan was not individualized and included identical goals and objectives as the treatment plan completed for client # 13.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Clinical Manager conducted an individual supervision session with the clinician who composed the identical treatment plans in two reviewed patient charts for the purpose of discussing the need and exemplifying multiple ways to individualize treatment plans.
The manager also discussed this issue in the Feb. 5, 2013 staff treatment plan, in-service session to increase the awareness of this issue with all clinical staff.
During at least the next 4 -6 months, the manager will review this issue and select patient charts with this clinician during their regularly scheduled staffing/supervision sessions.
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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 a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services in six of seven outpatient client records.
The findings include:
Eleven outpatient client records were reviewed on January 7 and January 22 - 23, 2013. Seven client records were reviewed for the type and frequency of treatment services in the individual treatment plan. The facility failed to document the type and frequency of individual counseling sessions in client records # 13, 14, 15, 16, 18 and 19.
Client # 13 was admitted into treatment on July 10, 2012. The individual treatment plan was completed on September 17, 2012. The client is participating in group and individual counseling. The facility failed to document the type and frequency of individual counseling sessions on the treatment plan of client # 13.
Client # 14 was admitted into treatment on July 26, 2012. The individual treatment plan was completed on July 26, 2012. The client is participating in group and individual counseling. The facility failed to document the type and frequency of individual counseling sessions on the treatment plan of client # 14.
Client # 15 was admitted into treatment on October 18, 2012. The individual treatment plan was completed on October 24, 2012. The client is participating in group and individual counseling. The facility failed to document the type and frequency of individual counseling sessions on the treatment plan of client # 15.
Client # 16 was admitted into treatment on December 22, 2012. The individual treatment plan was completed on January 12, 2013. The client is participating in individual counseling. The facility failed to document the type of counseling sessions on the treatment plan of client # 16.
Client # 18 was admitted into treatment on October 31, 2012. The individual treatment plan was completed on November 5, 2012. The client is participating in group and individual counseling. The facility failed to document the type and frequency of individual counseling sessions on the treatment plan of client # 18.
Client # 19 was admitted into treatment on November 28, 2012. The individual treatment plan was completed on December 3, 2012. The client is participating in group and individual counseling. The facility failed to document the type and frequency of individual counseling sessions on the treatment plan of client # 19.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the January 30, 2012 licensing inspection.
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Plan of Correction
The Clinical Manager conducted and in-service on treatment plans during two consecutive staff meetings (Jan. 29 and Feb 5, 2013). As part of the in-service the manager reviewed the regulatory standards and this citation with the staff. Type and frequency of services was one focus of review. Staff members are to specifically write the type and frequency of services as the first action step of each treatment plan. Written plans for all levels of care were exemplified for staff.
Also the Clinical Manager will review and sign all treatment plans and will now ensure that the appropriate and required type and frequency of services are written in each plan before final saved in the electronic medical record.
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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 that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in two of four outpatient client records.
The findings include:
Eleven outpatient client records were reviewed on January 7 and January 22 - 23, 2013. Four client records were reviewed for documentation of treatment plan updates and were required to include an assessment of the client's progress in relationship to the stated goals. The facility failed to document treatment plan updates that included an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in client records # 15 and 18.
Client # 15 was admitted into treatment on October 18, 2012. The comprehensive treatment plan was completed on October 24, 2012. A treatment plan update was completed on December 20, 2012 but did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
Client # 18 was admitted into treatment on October 31, 2012. The comprehensive treatment plan was completed on November 5, 2012. A treatment plan update was completed on January 3, 2013 but did not include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
On 2/5/13, the Clinical Manager conducted an in-service session with the clinical staff and demonstrated how they can more completely document treatment plan updates in the agency's new EMR. The treatment plan review document is constructed whereby staff can document "notes" associated with each objective in the plan.
The Manager will review and electronically sign each treatment plan and review and will ensure that the clients' progress or lack of progress on the stated goals and objectives are included and before final saving the document.
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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 client records, the facility failed to document follow-up information in two of four outpatient client records.
The findings include:
Eleven outpatient client records were reviewed on January 7 and January 22 - 23, 2013. Four client records were closed and were due for a follow-up attempt. Per facility policy, a follow-up will be conducted within 6 months of the client's discharge. The facility failed to document a follow-up attempt in client records # 9 and 12.
Client # 9 was admitted into treatment on May 8, 2012 and discharged on June 5, 2012. A follow-up attempt was due to be completed no later than December 5, 2012. There was no documentation of follow-up information in client record # 9 as of January 23, 2013.
Client # 12 was admitted into treatment on April 16, 2012 and discharged on June 14, 2012. A follow-up attempt was due to be completed no later than December 14, 2012. There was no documentation of follow-up information in client record # 12 as of January 23, 2013.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the January 14, 2010, January 10, 2011 and January 30, 2012 licensing inspections.
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Plan of Correction
In his review of this citation and the two charts involved, the Director determined that the patient discharges both occurred in June/2012. During that month the facility experienced a staff transition of work duties, which appeared to cause difficulties with these two patient follow-ups.
The director has re-assigned the administrative assistant to ensure that the follow-up contacts will be conducted as assigned and as per the established policy and procedures.
On at least a bi-monthly basis, the Clinical Manager will monitor and compare the list of follow-up contact attempts with the corresponding list of discharged patients' charts, to ensure all patients are involve with the follow-up process.
The Administrative assistant will report the results of the follow-up contacts on, at least, a bi-monthly basis to the director.
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