INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 22, 2010 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 and a plan of correction is due on January 19, 2011.
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Plan of Correction
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709.83(a)(11) LICENSURE Client records
709.83. 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 and an interview with the facility director, the facility failed to document follow-up information per facility policy in two of three client records.
The findings included:
Fifteen client records were reviewed on December 22, 2010. Six client records were reviewed as partial hospitalization client records. Policy states the the client will receive follow up contact 30 days after discharge. Three partial hospitalization client records were required to have follow-up information completed. The facility did not document follow up information per policy in client records #10 and 11.
Client # 10 was admitted on August 4, 2010 and discharged on October 8, 2010. Follow up contact was due on November 8, 2010 . There was no documentation that follow up contact had been attempted or made.
Client # 11 was admitted on June 7, 2010 and discharged on July 29, 2010. Follow up contact was due on August 29, 2010. Documentation showed that the follow up contact was completed on October 6, 2010.
The facility director was interviewed on December 22, 2010 and confirmed that there was no additional documentation available to show follow up had been completed per agency policy in client records # 10 and 11.
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Plan of Correction
The Program Director will assist the VP of Therapy programs to revise the policy and procedures (P & Ps) relative to follow-up contacts with discharged patients.
The new policy will include that Gateway's satellite facilities will attempt telephone follow-up contacts for their respective discharged patients by no more than 6 months after patient discharges. This will ensure that each satellite facility will be responsible for follow-up contacts and the related documentation and that this will occur before the closed patient charts are submitted to the medical records department for storage.
Once the new P & Ps are approved by administration, each satellite facility will conduct staff training on the new P & Ps, which will be implemented by February 28, 2011.
The director will assign the administrative assistant to ensure that the follow-up contacts will be conducted as assigned. 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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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 the review of client records and interviews with the clinical supervisor and facility director, the facility failed to document an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services in two of five client records.
The findings include;
Fifteen client records were reviewed on December 22, 2010. Nine client records were reviewed as outpatient client records. Five outpatient client records were required to have an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services. The facility did not document the type and frequency of treatment and rehabilitation services in client records # 5 and 6.
Client # 5 was admitted on September 9, 2010. The treatment and rehabilitation plan was completed on October 4, 2010. The plan did not document the type and frequency of treatment and rehabilitation services.
Client # 6 was admitted on October 22, 2010. The treatment and rehabilitation plan was completed on October 23, 2010. The plan did not document the type and frequency of treatment and rehabilitation services.
The facility director and clinical supervisor were interviewed on December 22, 2010 and confirmed the type and frequency of treatment and rehabilitation services were not documented on the treatment plans.
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Plan of Correction
On January 18, 2011, the Clinical Manager conducted a focused inservice with the facility staff on treatment planning, including the need to consistenly document the type and frequency of treatment and rehabilitation services in every written treatment plan.
The clinical manager will monitor treatment plan documentation during various scheduled cart reviews thoughout each patient's active treatment. This will ensure complete and correct treatment plan documentation and will provide ongoing opportunities for supervison and training of staff relative to treatment planning. |