INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30 - 31, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Erie 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection conducted on January 30, 2013, the facility failed to ensure that exits from the nonresidential facility were unobstructed.The findings include:A physical plant inspection was conducted with the facility director and assistant director on January 30, 2013 at approximately 1:30 PM. During the physical plant inspection, it was discovered that the second emergency exit was locked and could not be utilized by the outpatient clients during an emergency. The facility failed to ensure that exits from the nonresidential facility were unobstructed and operable at all times.The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Program Director in conjunction with the Gateway Director of Facilities Maintenance contracted to tie the door in question into the Fire Alarm System. In the event of a fire, the door lock will disengage;thus providing an alternative exit to the outpatient facility.
The testing of the function of the equipment will be part of the monthly fire drill. The contracted alarm provider will check the operation of the device quarterly.
The facility will be in full compliance before the 03/03/2013 target date. The Program Director will insure comliance. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on a review of medication administration records, the facility failed to document whether the client self-administered or rejected the prescribed medication in two of three medication administration records.The findings include:Medication administration records for three clients were reviewed on January 30, 2013. Per facility policy, staff will document whether the client has self-administered or rejected their prescribed medications. The facility failed to document whether the client self-administered or refused prescribed medication in client records # 2 and 16.Client # 2 was prescribed lisinopril 20 mg daily on January 3, 2013. There was no documentation as to whether the client self-administered or refused this prescribed medication on the following dates: January 6, 2013, January 8, 2013 and January 12 - January 30, 2013.Client # 16 was prescribed melatonin 3 mg at bedtime. There was no documentation as to whether the client self-administered or refused this prescribed medication from January 1 - January 29, 2013. The client was also prescribed levothyroxine 75 mg daily. There is no documentation as to whether the client self-administered or refused this prescribed medication from December 27 - 31, 2012.The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Documentation of rejection of medication will be added to the internal protocol for Administration of medication on February 19,2013. In addition a memo to the Program Director will be generated by third shift Monitor indicating those who have failed to take their medication. The Program Director will oversee compliance according to process and clinical rammifications.
The target for the POC is 02/19/2013 |
709.93(a)(1) 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:
(1) Consent forms.
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Observations
Based on a review of client records, the facility failed to document a follow-up consent form at intake, as per facility policy, in three of three outpatient client records.The findings include:Six outpatient client records were reviewed on January 31, 2013. Three client records were reviewed for follow-up consent forms. Per facility policy, a consent to follow-up form will be completed with the client during the intake process. The facility failed to document a follow-up consent form in client records # 13, 14 and 15.Client # 13 was admitted into treatment on October 2, 2012 and discharged on November 27, 2012. There was no documentation of a follow-up consent form in client record # 13, as of January 31, 2013.Client # 14 was admitted into treatment on November 21, 2012 and discharged on December 17, 2012. There was no documentation of a follow-up consent form in client record # 14, as of January 31, 2013.Client # 15 was admitted into treatment on July 19, 2012 and discharged on November 19, 2012. There was no documentation of a follow-up consent form in client record # 15, as of January 31, 2013.The assigned counselor was interviewed on January 31, 2013 and confirmed the findings.
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Plan of Correction
On February 4,2013 The Program Director met with the Out Patient therapist to review current deficiencies. The therapist was directed to add Consents for Follow Up to the Intake Process. Compliance will be monitored on a monthly basis during surpervision sessions with the Program Director.
The Program Director is responsible with quality assurance.
Target date for review of completion is March 4,2013 |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document individual counseling sessions on the record of services provided in two of four outpatient client records.The findings include:Six outpatient client records were reviewed on January 31, 2013. Four client records were reviewed for documentation of a record of services provided. The facility failed to document individual counseling sessions on the record of services provided in client records # 10 and 11.Client # 10 was admitted into treatment on September 26, 2012. The client is receiving weekly individual counseling sessions. The facility failed to document individual counseling sessions on the record of services provided for client # 10 from October 10, 2012 through January 30, 2013.Client # 11 was admitted into treatment on October 24, 2012. The client is receiving weekly individual counseling sessions. The facility failed to document individual counseling sessions on the record of services provided from October 24, 2012 through January 30, 2013.The assigned counselor was interviewed on January 31, 2013 and confirmed the findings.
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Plan of Correction
On February 4,2013 The Program Director met with the Out Patient therapist to review current deficiencies. The therapist was directed to add documentation of Record of Service to the Patient Record.Compliance will be monitored on a monthly basis during surpervision sessions with the Program Director.
The Program Director is responsible with quality assurance.
Target date for review of completion is March 4,2013
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation every 90 days, as per facility policy, in two of two outpatient client records.The findings include:Six outpatient client records were reviewed on January 31, 2013. Two client records required case consultations. Per facility policy, case consultations will be completed every 90 days for outpatient clients. The facility failed to document case consultations in client records # 10 and 11.Client # 10 was admitted into treatment on September 26, 2012. A case consultation was due to be completed no later than December 26, 2012. There was no documentation of a case consultation for client # 10, as of January 31, 2013.Client # 11 was admitted into treatment on October 24, 2012. A case consultation was due to be completed no later than January 24, 2013. There was no documentation of a case consultation for client # 11, as of January 31, 2013.The assigned counselor was interviewed on January 31, 2013 and confirmed the findings.This is a repeat citation from the January 25 - 26, 2012 licensing inspection.
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Plan of Correction
On February 4,2013 The Program Director met with the Out Patient therapist to review current deficiencies. The therapist was directed to add a Case Consultation to the Patient Record every 90 days.Case Cosultation will be reviewed by the treatment team during weekly meetings. Compliance will be monitored on a monthly basis during surpervision sessions with the Program Director.
The Program Director is responsible with quality assurance.
Target date for review of completion is March 4,2013
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within seven days of discharge in two of three outpatient client records.The findings include:Six outpatient client records were reviewed on January 31, 2013. Three client records were closed and required documentation of a discharge summary. Per facility policy, a discharge summary will be completed within seven days of discharge. The facility failed to document a discharge summary within seven days of discharge in client records # 13 and 15.Client # 13 was admitted into treatment on October 2, 2012 and was discharged on November 27, 2012. A discharge summary was due to be completed no later than December 4, 2012 . The discharge summary in client record # 13 did not include the date the discharge summary was completed. It was not possible to determine if the discharge summary was completed within seven days of the client's discharge from treatment. Client # 15 was admitted into treatment on July 19, 2012 and was discharged on November 19, 2012. A discharge summary was due to be completed no later than November 26, 2012 . The discharge summary in client record # 15 did not include the date the discharge summary was completed. It was not possible to determine if the discharge summary was completed within seven days of the client's discharge from treatment. The assigned counselor was interviewed on January 31, 2013 and confirmed the findings.This is a repeat citation from the January 25 - 26, 2012 licensing inspection.
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Plan of Correction
On February 4,2013 The Program Director met with the Out Patient therapist to review current deficiencies. The therapist was directed to complete the Dischage Summary within seven days of the completion of treatment.Compliance will be monitored on a monthly basis during surpervision sessions with the Program Director. A checklist of Out Patient deficiencies will guide monitoring of compliance.
The Program Director is responsible with quality assurance.
Target date for review of completion is March 4,2013
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