INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2013 by staff from the Division of Drug and Alcohol 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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709.82(a) 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:
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Observations
Based on a review of client records, the facility failed to document the development of an individual treatment and rehabilitation plan with the client in two of four partial hospitalization client records.
The findings include:
Eight partial hospitalization client records were reviewed on January 8 and January 25, 2013. Four client records were reviewed for an individual treatment plan that was developed with the client. The facility failed to document the development of an individual treatment plan with the client in client records # 5 and 6.
Client # 5 was admitted into treatment on December 17, 2012. An individual treatment plan was completed by the counselor on December 19, 2012. The treatment plan was not signed by client # 5 until December 21, 2012. Per review of the record of services provided, the client was present in treatment on December 19, 2012. Progress notes reviewed for this date did not indicate the discussion of treatment plan goals with the client. The facility failed to document the development of an individual treatment plan with client # 5.
Client # 6 was admitted into treatment on October 31, 2012. An individual treatment plan was completed by the counselor on November 2, 2012. The treatment plan was not signed by client # 6 until November 5, 2012. Per review of the record of services provided, the client was present in treatment on November 5, 2012. Progress notes reviewed for this date date did not indicate the discussion of treatment plan goals with the client. The facility failed to document the development of an individual treatment plan with client # 6.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
During two staff meetings (on January 29 and February 12, 2013, the Clinical Manager conducted in-services on Treatment Plans. This included a review of the regulatory standards and Gateway's policies and procedures regarding treatment plans.
Examples of treatment plans and associated progress notes, which indicated a discussion of treatment plan goals and plan development with the clients, were provided. Discussions occurred regarding the need to clearly identify and document the patient's involvement with treatment plan development.
From Feruary 12, 2013 forward, during the routine staffing of patient cases, when treatment planning is discussed, the Clinical Manager will consistently check with each staff member to ensure that the patient is not only involved with treatment plan development, but the staff member documents that this has occurred.
This has become an ongoing protocol which occurs in all staffing sessions and will continue on an ongoing basis.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary written consent from the client for the disclosure of information contained in the client record in two of eight client records.
The findings include:
Eighteen client records were reviewed on January 8 and January 25, 2013. Ten client records were reviewed for informed and voluntary written consents from the client. The facility failed to document an informed and voluntary written consent from the client prior to releasing client information to a funding entity in client records # 5 and 16.
Client # 5 was admitted into treatment on December 17, 2012. Client information was released to a funding entity on December 31, 2012. The facility failed to obtain an informed and voluntary written consent from client # 5 prior to releasing client information to this funding entity.
Client # 16 was admitted into treatment on December 22, 2012. Client information was released to a funding entity on December 26, 2012. The facility failed to obtain an informed and voluntary written consent from client # 16 prior to releasing client information to this funding entity.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
During a staff meeting on February 5, 2013, the Clinical Manager conducted an in-service on Gateway's established policies and procedures of acquiring and writing patient consents, including those related to the patient's funding source.
Although funding resource consents are frequently prepared with patients by the admission staff, the therapy staff must and will confirm that the appropriate consent(s) have been completed and available. If a needed consent is not available, the therapy staff will ensure that the appropriate consent is completed with the patient before any communication with the funding resources or any other entity requesting communication about the patient.
Also the Clinical Manager, with the assistance of the Administrative Assistance, will audit all charts for needed consents, within the first 2 days of the patient's treatment event. This began on February 6, 2013 and will continue on an ongoing basis.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included a clinical assessment of the client in two of six outpatient client records.
The finding include:
Ten outpatient client records were reviewed on January 8 and January 25, 2013. Six client records were reviewed for psychosocial evaluations that included a clinical assessment of the client. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client in client records # 14 and 15.
Client # 14 was admitted into treatment on November 21, 2012. A psychosocial evaluation was completed on September 10, 2012. The psychosocial evaluation did not include a clinical assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors and only included client reported historical information.
Client # 15 was admitted into treatment on October 22, 2012. A psychosocial evaluation was completed on October 23, 2012 . The psychosocial evaluation did not include a clinical assessment of the client's assets/strengths, support systems, coping mechanisms and negative factors and only included client reported historical information.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Regarding the issue of appropriately completing psychosocial evaluations, the Clinical Manager conducted in-service sessions with clinical staff on 1/29/2013 and again on 2/12/2013. The regulatory standards as well as examples of well written documents and incomplete written documents were reviewed and discussed.
During February and March, 2013, the Clinical Manager will specifically audit the completeness and quality of all psychosocial evaluations composed by staff before the documents are final saved in the agency's EMR and will review her findings with the respective staff in either individual or group supervision sessions. After this initial 2 month period, the manager will review this document on an ongoing basis as part of her routine supervision and staffing sessions.
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