INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and buprenorphine monitoring inspection. The inspection was conducted on October 11-13, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Gateway Rehabilitation Center 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 the inspection:
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
The facility failed to document that each counselor completed at least 25 hours of training for the 2016 training year.
Eleven counselor training records were reviewed on October 2-4, 2017. The training hours for the 2016 training year were reviewed (January - December). Counselor #6, 7, 9, 10 and 11 did not have documentation of at least 25 hours of training.
Counselor # 6 had 16.5 hours of training documented for 2016.
Counselor # 7 had 21 hours of training documented for 2016.
Counselor # 9 had 19.5 hours of training documented for 2016.
Counselor # 10 had 16.5 hours of training documented for 2016.
Counselor # 11 had 16.5 hours of training documented for 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors and counselors will receive the necessary 25 hours of training that is required yearly. Their compliance and adherence will be monitored by their direct supervisor quarterly. Supervisors were electronically educated on this process 11/28/2017.
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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.
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Observations
1.The facility failed to obtain an informed and voluntary consent to the funding source for the disclosure of client information in eleven of the eleven client records reviewed on October 11-13, 2017.
Releases of information to the funding source failed to include the name/agency/organization to whom the information would be disclosed in client records #1 - #11.
2.The facility failed to document compliance with Pa Code 255.5. The facility documents on the Assignment of Benefits form that the facility's President/Chief Executive Officer has the authority to approve the release of additional information to the insurance company if necessary to process claims. This is incorrect; the information released to the funding source is limited to the information outlined in Pa Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The release of information to an insurance company shall specify the insurance company and limit the release of information to the following:
Whether the client is or is not in treatment; The prognosis of the patient; the nature of the project; a brief description of the progress of the patient; a short statement as to whether the patient has relapsed into drug and alcohol abuse and the frequency of such relapse.
The Director of Health Information Management educated all applicable staff to this revision through electronic communication on November 1, 2017
The Director of Health Information Management will conduct admission chart audits (after each client admission) to ensure compliance with the Consent for Insurance and, in turn will share audit results with Program Directors.
In turn, the Director of Health Information Management educated all applicable staff to this revision through electronic communication also on November 1, 2017
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document that clients were informed of all the required client rights.
Three client handbooks (Residential, Youth and Outpatient) were reviewed on October 11-13, 2017. The clients sign a form acknowledging the receipt of the handbook. None of the three handbooks presented contained all of the required client rights as required by regulation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All handbooks were and will be reviewed by program Directors and modified to ensure proper documentation of client rights according to DDAP regulation 709.30. For the handbooks that were previously printed, the Director of each program and/or location will ensure that each hand book has an addendum with the updated client rights. Addendums were printed and distributed to program Directors/Managers November 15, 2017
The "Patient Treatment Agreement " form already exists and provides a signed acknowledgement of receipt of the patient handbook.
As directed by the Program Director, the facility's Admissions Officers/ Assistants will order the printed patient handbook as supplies are needed and will ensure that the correct version of the patient rights is included in the handbook.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to document a written notification of involuntary termination in one of one client record reviewed on October 11-13, 2017.
Client #9 was admitted on September 17, 2017 and involuntarily terminated from treatment on September 20, 2017. There was no documentation of written notification of termination in client record #9.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The patient will receive a copy Termination of Treatment form from the therapist, which serves as the written notification to of the patient's involuntarily termination of treatment. The notification states why the patient can no longer remain in the facility and the date they were discharged.
Gateway Rehab policy states , a copy of the Termination of Treatment forms are mailed to the any client that does not receive a copy at the time of discharge. This information is documented on the Termination of Treatment form
The Health Information Management Department Analyzers will conduct discharge chart audits on all discharges including involuntary discharges within 48 hours post-discharge to ensure compliance.
The Director of Health Information Management will educate all applicable staff to the new Termination of Treatment Policy and Procedure through electronic communication by 11/17/2017.
The Health Information Management Department Analyzers will conduct discharge chart audits on all discharges including involuntary discharges within 48 hours post-discharge to ensure compliance. The Department Director will be alerted immediately to any issues with the completion of the form and will follow up with the specific staff member and provide instruction when necessary. The Director of Health Information Management and Department Director will ensure this process is taking place on an on-going basis.
The Facility Director has ensured this issue was corrected by 12/1/2017. The Facility Director, along with the Department Directors stated above, will ensure the POC is followed on an on-going basis through informal audits during treatment and formal audits after discharge.
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
The facility failed to file an unusual incident report with the Department within 3 business days following an incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
The unusual incident reports were reviewed on October 11-13, 2017. Incident reports for incidents that occurred on October 29, 2016, July 23, 2017 and August 20, 2017 were not received by the Department within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing and/or member of the Nursing Leadership Team beginning October 13, 2017 will review 100% of all unusual incidents to include the following:
Accurate description of incident
Confirm that DDAP has received report within 3 business days as evidenced by fax confirmation
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