INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 22, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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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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 a review of client records, the facility failed to document follow up contact in two of two client records.Four discharged clients were reviewed. Follow up was refused in two of the client records. The facility policy states that follow up will occur 30 days post discharge. Follow up was not conducted as per facility policy in client records #4 and #7.Client #4 was admitted on June 15, 2020 and discharged on September 11, 2020. Follow up was due to be completed by October 11, 2020. There was no follow up documented in client record #4.Client #7 was admitted on February 26, 2020 and discharged on May 5, 2020. Follow up was due to be completed by October 11, 2020. There was no follow up documented in client record #7.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy & Procedure 515 Staff Follow-Up will be revised to include the following revision:
All residential programs will complete Follow-Up when patient agrees to Consent to Staff Follow-Up either by telephone, mail or both within 30 days post-discharge.
All applicable staff will be educated on the revised Policy & Procedure.
The Health Information Management Department will audit 100% of Discharges whereby Patient Consent for Staff Follow-Up was secured for 3 months.
Staff Follow-Up Audit results will be shared with the appropriate Program Director and Vice President.
Completion Date: 05/15/2021
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