INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25 - 26, 2012 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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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 on a review of personnel training records, the facility failed to document individual training plans by December of each year, as per facility policy, in four of four personnel records.
The findings include:
Five personnel training records were reviewed on January 3 - 5, 2012. Four personnel training records were reviewed for individual training plans. Per facility policy, training plans will be completed by the end of each year in December. The facility's training year is from January through December. Training plans were reviewed for the 2011 training year and were due to be completed no later than December 31, 2010.
The facility failed to document individual training plans by December 31, 2010 in personnel training records # 1, 2, 3 and 4. Training plans for these employees were completed between January 27 and February 17, 2011.
The facility director and human resources director were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
The Vice president of Human Resources has proposed a revision to the Gateway Rehabilitation Center's Policy and Procedure for Staff Training and Development which reflects our current practice and procedure. The policy will specify completion of the Training Plan by February first.The change specifies that supervisory staff will develop a training plan based upon a calendar of events throughout the year in January. The calendar includes: training needs,topics and hours from various outside sources, licensing and regulatory groups, and external/internal training events. The Human Resource staff will assist the supervisors in the development of the training calendar. Training Plans are completed as of February 1,2012
The process is overseen by the Program Director. |
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 the facility's policy and procedure manual and client records, the facility failed to document follow-up information in one of two inpatient client records.
The findings include:
Twelve client records were reviewed on January 25 - 26, 2012. Six client records pertained to the inpatient non-hospital activity. Three client records were closed. Two client records required documentation of a follow-up attempt. One client record was not yet due for a follow-up. Per agency policy, a follow-up will be conducted within six months of discharge. The facility failed to conduct a follow-up within six months of discharge in client record # 5.
Client # 5 was admitted into treatment on May 24, 2011 and discharged on July 8, 2011. A follow-up attempt was due to be completed no later than January 8, 2011. The facility failed to provide documentation of a follow-up attempt as of January 26, 2012.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the January 11 - 12, 2011 and January 20 - January 21, 2010 licensing inspections.
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Plan of Correction
When charts are archived following completion of the discharge summary a checklist is included which is signed off by the Program Director. The POC is to include instructions for follow up as an item on the checklist.This will attest that proper documents are sent to the Research Department in order that Research may complete follow up.If the Program Director identifies that follow up documentation has not occurred, they will contact the Primary Therapist as a matter of supervision. Charts are archieved on a monthly basis.
This process will begin in charts archieved in February 2012.
The Program Director will oversee this process. |
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 on a review of client records, the facility failed to document psychosocial evaluations that included a clinical assessment of the client in three of four outpatient client records.
The findings include:
Twelve client records were reviewed on January 25 - 26, 2012. Six client records pertained to the outpatient activity. Four client records were reviewed for the completion of psychosocial evaluations. The psychosocial evaluations in three client records did not include a clinical assessment of the client; and only included client historical information. The facility failed to document a psychosocial evaluation that included a clinical assessment of the client in client records # 7, 8 and 9.
Client # 7 was admitted into treatment on January 16, 2012. The psychosocial evaluation was completed on January 16, 2012. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
Client # 8 was admitted into treatment on January 9, 2012. The psychosocial evaluation was completed on January 9, 2012. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
Client # 9 was admitted into treatment on December 20, 2011 and discharged January 19, 2012. The psychosocial evaluation was completed on December 20, 2011. The psychosocial evaluation did not include a clinical assessment of the client and only included client historical information.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
In a meeting with the Program Director and the Out Patient Therapist held on Friday February 3,2012, the Program Director conducted a training in the expectations for a Psycho social evaluation. Reviewed were standards for subjective analysis of clinical impressions as well as an analysis of strengths and weaknesses, coping mechanisms, social supports beyond mere historical data.
The therapist will present evidence of compliance with this standard for the next three months or until the Program Director is satisfied that the standard has been met.
Target date for full compliance is no later than April 30,2012.
The Program Director will oversee compliance |
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 the provider of counseling sessions on the record of services provided in four of six outpatient client records. In addition, the facility failed to document a record of services provided in two of six outpatient client records
The findings include:
Twelve client records were reviewed on January 25 - 26, 2012. Six client records pertained to the outpatient activity and required a record of services provided. The facility failed to document the provider of counseling sessions on the record of services provided in client records # 9, 10, 11 and 12. The facility failed to document a record of services provided in client records # 7 and 8.
Client # 7 was admitted into treatment on January 16, 2012. The client was receiving group and individual counseling sessions. There was no record of services provided in client record # 7, as of January 26, 2012.
Client # 8 was admitted into treatment on January 9, 2012. The client was receiving group and individual counseling sessions. There was no record of services provided in client record # 8, as of January 26, 2012.
Client # 9 was admitted into treatment on December 20, 2011 and discharged on January 19, 2012. The client was receiving group and individual counseling sessions. The record of services provided failed to document the provider of services for any of the group and individual sessions.
Client # 10 was admitted into treatment on June 1, 2011 and discharged on June 30, 2011. The client was receiving group and individual counseling sessions. The record of services provided failed to document the provider of services for any of the group and individual sessions.
Client # 11 was admitted into treatment on June 9, 2011 and discharged on June 22, 2011. The client was receiving group and individual counseling sessions. The record of services provided failed to document the provider of services for any of the group and individual sessions.
Client # 12 was admitted into treatment on June 7, 2011 and discharged on July 7, 2011. The client was receiving group and individual counseling sessions. The record of services provided failed to document the provider of services for any of the group and individual sessions.
The facility director was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
In a meeting conducted with the Program Director and the Out Patient Therapist held on Friday February 3,2012, a discussion was held involving compliance with the standard. The Therapist contention of logic,that they are the only one conducting sessions was disputed.The standard to identify who conducted the session, indicated by the therapist initials on the record of service was repeated by the Program Director. We will review compliance for the next three months in supervisory sessions.
Target date for full compliance is April 30 2012.
The Program Director will oversee compliance |
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 three of three outpatient client records.
The findings include:
Twelve client records were reviewed on January 25 - 26, 2012. Six client records pertained to the outpatient activity. Three outpatient 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 # 10, 11 and 12.
Client # 10 was admitted into treatment on June 1, 2011 and was discharged on June 30, 2011. A discharge summary was due to be completed no later than July 7, 2011. The discharge summary in client record # 10 did not include a date. It was not possible to determine if the discharge summary was completed within seven days of the client's discharge from treatment.
Client # 11 was admitted into treatment on June 9, 2011 and was discharged on June 22, 2011. A discharge summary was due to be completed no later than June 29, 2011. The discharge summary in client record # 11 did not include a date. It was not possible to determine if the discharge summary was completed within seven days of the client's discharge from treatment.
Client # 12 was admitted into treatment on June 7, 2011 and was discharged on July 7, 2011. A discharge summary was due to be completed no later than July 14, 2011. The discharge summary in client record # 12 did not include a date. It was not possible to determine if the discharge summary was completed within seven days of the client's discharge from treatment.
The facility director was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
The Out Patient Therapist will adopt the same standards of documentation as the In Patient Therapist utilizing a narrative as opposed to a checklist for a Discharge Summary. This document is included in the Gateway Charting Manual.
The Program Director will meet with the Out Patient Therapist in the next scheduled supervisory session to direct this process. Compliance will be monitored in the next three months or until the Program Director is satisfied with compliance.
Targeted date of full compliance is April 30 2012.
The Program Director along with the Therapist will insure compliance. |
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.
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Observations
Based on a review of the facility's policy and procedure manual and client records, the facility failed to document follow-up information in one of one outpatient client record.
The findings include:
Twelve client records were reviewed on January 25 - 26, 2012. Six client records pertained to the outpatient activity. Four client records were closed. One client record required documentation of a follow-up attempt. Per agency policy, a follow-up will be conducted within six months of discharge. The facility failed to conduct a follow-up within six months of discharge in client record # 10.
Client # 10 was admitted into treatment on June 1, 2011 and discharged on June 30, 2011. A follow-up attempt was due to be completed no later than December 30, 2011. The facility failed to provide documentation of a follow-up attempt as of January 26, 2012.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the January 11 - 12, 2011 and January 20 - January 21, 2010 licensing inspections.
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Plan of Correction
When charts are archived following discharge a checklist of essential items is reviewed by the Program Director. A revised checklist will include documentation that follow up has been sent to the Research Department
for completion of follow up.If the Program Director identifies that follow up documentation is not present they will contact the Primary Therapist as a matter of supervision.
This process wil begin in charts archieved in March 2012.
Full compliance is targeted for March 2012.
The Program Director will oversee compliance. |