INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 20-21, 2010 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 and a plan of correction is due on
|
Plan of Correction
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to ensure that each counselor met the qualifications for the position in one of three personnel records.
Findings:
Nine personnel records were reviewed on January 4-5, 2010. The facility director was interviewed on January 20, 2010. Three personnel records were reviewed for their qualifications for the position of counselor. The facility did not provide documentation, in personnel record # 5, that the counselor met at least one of the qualifications for the position of a counselor.
In personnel record # 5, the counselor did not meet the qualifications for the position of counselor based on a Bachelor of Science degree in Administration of Justice. In addition, the bachelor's degree course transcript was reviewed by the Division on January 5, 2010 and was found not to meet the educational component for the position of counselor.
|
Plan of Correction
Human resouces will scrutinize all future candidates in order to meet the requirements of counselor.
The Program Director will supervise this individual until they are able to meet the standard for Counselor. The individual's training plan has been modified to include the re-acquisition of a lapsed CAC within the alloted time framework.
The individuals title and job description will change to that of counselor assistant when they work with inpatient's part time.
This will be reviewed by the Director of the Correction's Division every six months.
The plan of correction will be in place by March 1,2010. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of personnel records, an interview with the facility director and the review of the CPR/first aid certification cards, the facility failed to provide a sufficient number of staff persons so that at least one person trained in these skills is onsite during the project's hours of operation.
The findings include:
Ten personnel records and employee CPR/first aid certification cards were reviewed on January 20-21, 2010. The facility director was interviewed on January 21, 2010. The facility did not document that at least one person trained in CPR/first aid was on site during the project's hours of operation on December 27, 28, 31, 2009 and January 2, 9, 11 and 16, 2010.
Employee #9, was the only person scheduled for the 11 PM to 7 AM on December 27, 28, 31, 2009 and January 2, 9, and 16, 2010. Employees # 9 and 10 were scheduled for the 11 PM to 7 AM on January 11, 2010. There was no documentation that either employee was currently certified in CPR.
|
Plan of Correction
As a matter of practice any individual who does not hold a current certification in CPR will not be scheduled to work.Other substitute staff will be scheduled should this occur. This process will be overseen by the individual's supervisor and reviewed by the training co-ordinator and the Program Director on a monthly basis.
Those individuals who were deficient have been recertified in CPR the following week after the inspection.
Other staff were informed during a staff meeting on 2/25/2010
The plan of Correction is completed as of this date. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of client records, the facility failed to document physical examinations at admission in three of six client records.
The findings include:
Eleven client records were reviewed on January 20-21, 2010. Physical examinations were required in six client records. The facility failed to complete physical examinations at the time of admission as required in client records # 2, 3, and 6.
In client record #2 the individual was admitted on October 15, 2009. The physical examination was to be completed by October 22, 2009, but was not completed until October 23, 2009.
In client record #3 the individual was admitted on August 17, 2009. The physical examination was to be completed by August 24, 2009, but was not completed until August 28, 2009.
In client record # 6, the individual was admitted on September 2, 2009. The physical examination was to be completed by September 9, 2009, but was not completed until September 11, 2009.
|
Plan of Correction
The Health Authority is scheduled to be here once a week for routine Histoy and Physical Examinations ;however,in the event that the patient would be unable to be seen within the perscribed seven days for some extenuating circumstance the Health Authority has agreed that we could transport the patient to a private practice designated by the Health Authority. This option did not exist at the time of inspection.
The Program Director will oversee compliance. The medical liason on staff will coordinate transport.
This process will be in place as of March 1,2010
Our decrease in licensed capacity will decrease the number of patients to make this process more managable.
|
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.
|
Observations
Based on a review of personnel records and interviews with the human resource director and the facility director, the facility failed to document follow-up information per facility policy in three of three client records.
The findings include:
Eleven client records were reviewed on January 20-21, 2010. The human resource director was interviewed on January 5, 2010 and the facility director was interviewed on January 20, 2010. Seven client records were reviewed as inpatient non hospital records. Policy states the the client will receive follow up contact at 1, 3, 6 and 12 months after discharge. Three inpatient non hospital client records were required to have follow-up information completed. The facility did not document follow up information in client records # 5, 6 and 7.
Client # 5 was admitted on June 19, 2009 and discharged on October 26, 2009. Follow up contact was due on November 26, 2009. There was no documentation that follow up contact had been attempted or made.
Client # 6 was admitted on September 2, 2009 and discharged on December 4, 2009. Follow up contact was due on January 4, 2010. There was no documentation that follow up contact had been attempted or made.
Client # 7 was admitted on July 28, 2009 and discharged on November 20, 2009. Follow up contact was due on December 20, 2009. There was no documentation that follow up contact had been attempted or made.
|
Plan of Correction
Gateway is currently in the process of updating its follow-up policy. Until that is completed, the Director of Research and Evaluation will monitor the follow-up process more closely to assure it is being completed as stated in our policy. The Director of the Extended Care Services Division will review this process with the Director of Research and Evaluation for all Correction's patients.
This process will be overseen by the Vice President Therapy Program and completed by 4/2010. |
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, and an interview with the facility director, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in four of four client records.
The findings include:
Eleven client records were reviewed on January 20-21, 2010. Four client records were reviewed as outpatient records. An individual treatment and rehabilitation plan which included the proposed type of support service was required in four client records. The facility did not document the proposed type of support services on the treatment plans in client records # 8, 9, 10 and 11.
Client # 8 was admitted on December 21, 2009. Support services were not documented in the client's individual treatment and rehabilitation plan.
Client # 9 was admitted on December 22, 2009. Support services were not documented in the client's individual treatment and rehabilitation plan.
Client # 10 was admitted on October 26 21, 2009. Support services were not documented in the client's individual treatment and rehabilitation plan.
Client # 11 was admitted on August 14, 2009. Support services were not documented in the client's individual treatment and rehabilitation plan.
|
Plan of Correction
Patient support services are to be documented in the Treatment Plan under Family and other Supports and are reflective of clinical judgement and not patient report. The Program Director has provided in-service education to the Clinical Staff on 2/4/2010 and reitterated on 3/2/2010. Included in this training was a standard for clinical evaluation of support services in the treatment Plan
The Program Director in the role of Therapy Manager and Clinical Supervisor will review this when
conducting monthly chart reviews and remediate problems should they occur. The Program Director is in charge of implementation as of March 1,2010. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to document the provision of treatment services consistent with the type and frequency specified in the treatment and rehabilitation plan in three of four client records.
The findings included:
Eleven client records were reviewed on January 20-21, 2010. Four were reviewed as outpatient client records. Four client records were required to document the provision of services in accordance with those specified in the treatment and rehabilitation plan. Services were not documented as stated in the treatment plans in records # 8, 9 and 10.
In client record # 8,the client was admitted on December 21, 2009. The client was to receive 2 individual and 2 group counseling sessions per week.
Documentation for the week of December 21, 2009, showed that the client received one individual session on December 21, 2009.
Documentation for the week of December 28, 2009, showed that the client had not received any individual sessions.
Documentation for the week of January 4, 2010, showed that the client received one individual session on January 5, 2010.
Documentation for the week of January 11, 2010, showed that the client had received one individual session on January 12, 2010.
In client record # 9, the client was admitted on December 22, 2009. The client was to receive 2 individual and 2 group counseling sessions per week.
Documentation for the week of December 21, 2009, showed that the client received one individual session on December 24, 2009.
Documentation for the the week of December 28, 2009, showed that the client had not received any individual sessions.
Documentation for the week of January 4, 2010, showed that the client received one individual session on January 5, 2010.
Documentation for the week of January 11, 2010, showed that the client had not received any individual sessions.
In client record # 10, the client was admitted on October 26, 2009 and discharged on December 2, 2009. The client was to receive 2 individual and 2 group counseling sessions per week.
Documentation for the week of October 26, 2009, showed that the client had received one individual session on October 26, 2009.
Documentation for the week of November 2, showed that the client had not received any individual sessions.
Documentation for the week of November 16, 2009, showed that the client had not received any individual sessions.
Documentation for the week of November 23, 2009, showed that the client had received one individual session on November 23, 2009.
|
Plan of Correction
The Program Director has instructed the Clinical Staff to provide specific reference to time frames for the provision of services: for example, if a treatment plan indicates that a patient is to be seen for individual counseling 2 times; that this reference specifies individual 2 times per week or individual 2 times during the duration of treatment. The same reference will be made for group,ie group 2 times a day,week,or month. This will be reviewed by the Program Director during monthly reviews for the next year to insure compliance.
This will insure that specific type of treatment and frequency will be addressed.
This plan of correction will be in place by March 1,2010 |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of personnel records and interviews with the human resource director and the facility director, the facility failed to document follow-up information per facility policy in two of two client records.
The findings include:
Eleven client records were reviewed on January 4-5 and 20-21, 2010. The human resource director was interviewed on January 5, 2010 and the facility director was interviewed on January 20, 2010. Four client records were reviewed as outpatient client records. Policy states the the client will receive follow up contact at 1, 3, 6 and 12 months after discharge. Two outpatient client records were required to have follow-up information completed. The facility did not document follow up information in client records # 10 and 11.
Client # 10 was admitted on October 26, 2009 and discharged on December 2, 2009. Follow up contact was due on January 2, 2010. There was no documentation that follow up contact had been attempted or made.
Client #11 was admitted on August 14, 2009 and discharged on September 17, 2009. Follow up contacts were due on October 17, 2009 and December 17, 2009. There was no documentation that follow up contacts had been attempted or made.
|
Plan of Correction
Gateway is currently in the process of Gateway is updating its follow-up policy. Until that is completed, the Director of Research and Evaluation will monitor the follow-up process more closely to assure it is being completed as stated in our policy. The Director of the Extended Care Services Division will review this process with the Director of Research and Evaluation for all Correction's patients.
This process will be overseen by the Vice President Therapy Program and completed by 4/2010.
|