INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29-30, 2008 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 and a plan of correction is due on February 29, 2008.
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Plan of Correction
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on the review of personnel records, the facility failed to properly document that
close supervision of the counselor assistants had occurred for the first six months of their employment. Review of the supervisory notes in six employee records showed that two records did not have proper documentation of supervision, #9 and 11. In record #9, for a 6 week period, the supervisory notes had been copied with the date changed. The supervisory notes for record #11 were copied from record #9 for a four week period.
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Plan of Correction
DIRECTOR AND CLINICAL MANAGER WILL MEET TO DISCUSS THE CURRENT SYSTEM OF WEEKLY SUPERVISION AND DOCUMENTATION THERE OF BY 2/21/2008. MANAGER WILL CONTINUE TO MEET WITH ALL COUNSELOR TRAINEES AND WRITE DAP FORMAT EACH WEEK EACH TRAINEE IS IN ATTENDENCE. NOTES TO BE REVIEWED BY DIRECTOR 1 TIME PER MONTH TO ENSURE COMPLETION. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based of the review of personnel records, the facility failed to complete an individual training plan in one of seven employee records, specifically employee record #1.
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Plan of Correction
THE PRESIDENT/CEO WILL COMPLETE AN ANNUAL TRAINING PLAN BY FEBRUARY 25, 2008. THIS WILL BE ENSURED BY THE V.P. OR HUMAN RESOURCES. CORPORATE COMPLIANCE. |
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 of the review of personnel records, the facility failed to document that staff persons receive the required minimum of four hours of STD/TB training. This occurred in one of seven employee records reviewed, specifically #7.
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Plan of Correction
THERAPY MANAGER AND REGIONAL DIRECTOR WILL CONTACT HR DEPT. TO REVIEW RECORD FOR VERIFICATION OF TRAINING BY 2/25/08. IF TRAININGS CANNOT BE VERIFIED,MANAGER WILL ENSURE DELINQUENT EMPLOYEE(S) WILL BE SCHEDULED AND ATTEND THE NEXT STATE APPROVED TB/STD TRAINING. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent form from clients in six of twelve records reviewed, specifically client records #7, 8, 9, 10, 11 and 12. Family members and friends of all clients were encouraged to attend family night group sessions and did attend, however these sessions were conducted as treatment sessions where the clients were identified as drug and alcohol clients. Consents to release information for releases to those attending who were not patients were missing in all six client records.
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Plan of Correction
1.Beginning immediately, all non-patient participants in family group sessions will read and sign a statement that they agree to keep any information they observe or hear in family group confidential, including a reminder of legal repercussions that might ensue if they violate a patient's confidentiality.
2. Beginning March 24, 2008, Gateway will have all patients sign a new consent at admission that informs the patient that, by signing the consent the are authorizing Gateway to release to any participant in the combined family group session who is not a patient, information that includes the patient's presence in treatment and any information that they verbally divulge during the session.
3. The purpose of this release is to allow Gateway to conduct regularly scheduled family group sessions during the course of the patient's treatment.
4. Gateway's Director of Medical Records and the Regional Program Directors will be responsible for the implementation of this plan.
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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 ob the review of client records, the facility failed to document a complete psychosocial evaluation in three of six records reviewed, specifically client records # 10, 11 and 12. The psychosocial evaluation did not address the client's coping mechanisms. In four of six records reviewed, the counselor's conclusions and impressions were not clinical or evaluative, but were historical in nature and contained comments from the client rather than the clinician's analysis of the collected historical information.
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Plan of Correction
CLINICAL MANAGER TO REVIEW THE SECTION ON PSYCHO-SOCIAL HISTORIES AND EVALUATION SUMMARY IN THE CHARTING MANUEL WITH THE CLINICAL STAFF. THIS REVIEW WILL BE HELD AT THE LAST STAFF MEETING IN THE MONTH OF FEBRUARY BEFORE 2/28/2008. THE CHART(S) IN QUESTION WILL BE USED AS EXAMPLE IN REVIEW AND AN ANALYTICAL SUMMARY WILL BE PRACTICED. THE CLINICAL MANAGER WILL VERIFY COMPLIANCE THROUGH WEEKLY CHART AUDIT. |