INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11-12, 2011 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 February 14, 2011.
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Plan of Correction
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the specific information to be disclosed in four of seven client records.
The findings included:
Ten client records were reviewed on January 1-12, 2011. Seven client records required an informed and voluntary consent from the client; including the specific information to be disclosed. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record; including the specific information to be disclosed. The facility failed to obtain an informed and voluntary consent from the client; including the specific information to be disclosed in client records # 2, 3, 7 and 8.
Client # 2 was admitted on December 13, 2010. The client record contained four releases of information signed by the client that did not include the specific information to be released. The information to be released was listed as "other" with no further definition of what the "other" information was that would be released.
Client # 3 was admitted on December 3, 2010. The client record contained three releases of information signed by the client that did not include the specific information to be released. The information to be released was listed as "other" with no information defining what the nature of the other information to be released would be. The client record also contained one release of information signed by the client, that did not identify what information was to be released.
Client # 7 was admitted on December 8, 2010. The client record contained three releases of information signed by the client that did not clearly identify the specific information to be released. The releases of information in the client record contained columns with lists of possible information to be released. The list in each column had a line drawn through it. The signed releases by the client did not document what information was to be released.
Client # 8 was admitted on November 29, 2010. The client record contained two releases of information signed by the client that did not clearly identify the specific information to be released. The releases of information in the client record contained columns with lists of possible information to be released. The list in each column had a line drawn through it. The signed releases by the client did not document what information was to be released.
The facility director was interviewed on January 12, 2011 and acknowledged that the consents to release information were unclear as to the specific information to be released.
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Plan of Correction
A staff training will be provided to all staff during the General Staff Meeting on Wednesday February 23,2011 @3pm to delineate the rules for informed and voluntary consent. The Program Director will provide this training. Supervisory followup will be monitored during subsequent monthly meetings for the duration of one year.
The Program Director will oversee continued compliance. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document an informed and voluntary consent from the client which included the purpose of the disclosure in four of seven client records.
The findings include:
Ten client records were reviewed on January 1-12, 2011. Seven client records required an informed and voluntary consent from the client; including the purpose of the disclosure. Per regulation, the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record; including the purpose of the disclosure. The facility failed to obtain an informed and voluntary consent from the client which included the purpose of the disclosure in client records # 2, 3, 7 and 8.
Client # 2 was admitted on December 13, 2010. The client record contained four releases of information signed by the client that did not include the purpose of the disclosure. The purpose of the disclosure was listed as "other" with no further definition of "other ".
Client # 3 was admitted on December 3, 2010. The client record contained three releases of information signed by the client that did not include the purpose of the disclosure. The purpose of the disclosure was listed as "other" with no further definition of "other ".
Client # 7 was admitted on December 8, 2010. The client record contained three releases of information signed by the client that did not include the purpose of the disclosure. The purpose of the disclosure was listed as "other" with no further definition of "other ".
Client # 8 was admitted on November 29, 2010. The client record contained two releases of information signed by the client that did not include the purpose of the disclosure. The purpose of the disclosure was listed as "other" with no further definition of "other ".
An interview with the project director on January 12, 2011 confirmed that the releases of information did not document the purpose of disclosure as required.
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Plan of Correction
A staff training will be provided to all staff during the General Staff Meeting on Wednesday February 23,2011 @3pm to delineate the rules for informed and voluntary consent. The Program Director will provide this training. Supervisory followup will be monitored during subsequent monthly meetings for the duration of one year.
The Program Director will oversee continued compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document a physical examination in one of four client records.
The findings include:
Ten client records were reviewed on January 11-12, 2011. Six client records were reviewed as inpatient client records. Per agency policy, a physical examination of the client is to be completed at admission. There was no documentation of a physical examination being completed in client record # 3.
Client # 3 was admitted on December 3, 2010. The physical examination was to be completed by December 3, 2010. There was no documentation as of January 12, 2011 that a physical examination had been completed.
An interview with the facility director on January 12, 2010 confirmed there was no documentation of a physical examination being completed on client #3.
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Plan of Correction
Weekly Supervisory review of the Doctors List will occur by the Medical Liason Officer to insure that Physical exams are completed upon admission. Discrepancies will be reported to the Program Director in order to utilize Community Resources to rectify the situation.
The Program Director will oversee compliance.
The standard will be in compliance as of March 1,2011. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 an interview with the facility director, the facility failed to document an individual treatment and rehabilitation plan which included the type and frequency of treatment services in four of four client records.
The findings include:
Ten client records were reviewed on January 11-12, 2011. Six client records were reviewed as inpatient client records. Per regulation, the individual treatment and rehabilitation plan shall include the type and frequency of treatment services. The facility did not document the type and frequency of treatment services in client records # 1, 2, 3 and 4.
Client # 1 was admitted on December 13, 2010. The individual treatment and rehabilitation plan was completed on December 23, 2010. There was no documentation of the type and frequency of treatment services the client was to receive.
Client # 2 was admitted on December 7, 2010. The individual treatment and rehabilitation plan was completed on December 17, 2010. There was no documentation of the type and frequency of treatment services the client was to receive.
Client # 3 was admitted on December 3, 2010. The individual treatment and rehabilitation plan was completed on December 15, 2010. There was no documentation of the type and frequency of treatment services the client was to receive.
Client # 4 was admitted on October 4, 2010 and discharged on November 18, 2010. The individual treatment and rehabilitation plan was completed on October 18, 2010. There was no documentation of the type and frequency of treatment services the client was to receive.
An interview with the project director on January 12, 2011 confirmed that the type and frequency of the treatment services the client was to receive was not documented.
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Plan of Correction
The standard for type and frequency of treatment will be discussed in a Clinical Staff meeting on 2/9/2011 @3pm.
All clinical staff will be directed to include type and frequency in the individual treatment and rehabilitation plan. Compliance will be monitored by the Program Director during monthly chart reviews.
The standard will be in full compliance as of March 1,2011.
The program director will insure compliance. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document group counseling notes as required by Licensing Alert 2-94 in three of four client records.
The findings include:
Ten client records were reviewed on January 11-12, 2011. Six client records were reviewed as inpatient client records. Per Licensing Alert 2-94, if group sessions are conducted, individual notes need not be written for each client. One group note will suffice provided that it includes a comment relative to each individual's response or participation in the group session. The facility did not document group notes as required in client records # 2, 3 and 4.
Client # 2 was admitted on December 7, 2010. There were no individual comments relative to the individual's response or participation in the group sessions for 14 of the group counseling sessions the client attended. The individual comments stated "attended".
Client # 3 was admitted on December 3, 2010. There were no individual comments relative to the individual's response or participation in the group sessions for 16 of the group counseling sessions the client attended. The individual comments stated "attended".
Client # 4 was admitted on October 4, 2010 and discharged on November 18, 2010. There were no individual comments relative to the individual's response or participation in the group sessions for 11 of the group counseling sessions the client attended. The individual comments stated " attended ".
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Plan of Correction
Delineation of Clinical vs Non Clinical notes will be made during a clinical staff meeting on 2/16/2011 @3pm. All Clinical notes are to be written in the prescribed DAP format. Emphasis is to be placed on the individual assessment as a true observation of the patients participation in the group process.
Compliance will be monitored during monthly chart reviews by the Program Director.
The standard will be in full compliance as of March 1,2011. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document that a discharge summary was completed per agency policy in two of three client records.
The findings include:
Ten client records were reviewed on January 11-12, 2011. Six client records were reviewed as inpatient client records. Three client records were closed and were required to include a discharge summary. Per agency policy, a discharge summary is to be completed within 7 days of the client's discharge date. The agency did not document a discharge summary as per policy in client records # 5 and 6.
Client # 5 was admitted on July 5, 2010 and discharged on August 25, 2010. The discharge summary was to be completed by September 1, 2010. The discharge summary documented in the client's record did not contain a completion date. There was no documentation provided that the discharge summary had been completed within 7 days of the client's discharge date.
Client # 6 was admitted on September 28, 2010 and discharged on October 26, 2010. The discharge summary was to be completed by November 2, 2010. The discharge summary documented in the client's record was completed on December 6, 2010.
The facility director was interviewed on January 12, 2011. No additional information or documentation was offered for review.
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Plan of Correction
The issue of timey discharge summary will be discussed during a clinical staff meeting on 2/16/2011. Compliance will be monitored by monthly chart reviews completed by the Program Director.
Staff compliance will be linked to the staff members annual Performance Evaluation.
The standard will be in full compliance as of March 1,2011.
The Program Director will insure compliance. |
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 the review of client records and an interview with the facility director, the facility failed to document that follow up was completed per agency policy in one of three client records.
The findings include:
Ten client records were reviewed on January 11-12, 2011. Six client records were reviewed as inpatient client records. Three client records were closed and were required to include documentation of the facility's attempt to follow up on the clients. Per agency policy, follow up is to be completed at 30 days. The facility did not document follow up in client record #6.
Client # 6 was admitted on September 28, 2010 and discharged on October 26, 2010. Follow up was to be completed by November 26, 2010. There was no documentation that a follow up had been attempted or completed as of January 12, 2010.
The facility director was interviewed on January 12, 2011. No additional information or documentation was offered for review.
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Plan of Correction
Arrangements have been made with the corporate Research Department to provide the necessary followup at the prescribed interval. The Vice President of therapy will oversee the process on a corporate Level.
Locally the Program Director will monitor compliance during monthly chart reviews.Data will be retrieved monthly via a memo requesting data generated by the Program Director
The proceedure is established as of February 1,2011. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document a medical history per agency policy in one of three client records where required.
The findings include:
Ten client records were reviewed on January 1-12, 2011. Four client records were reviewed as outpatient client records. Per agency policy, the medical history is to be completed at intake. The facility did not document a medical history per agency policy in client record # 8.
Client # 8 was admitted on November 29, 2011. The medical history was to be completed by November 8, 2011. The documented medical history was not completed until December 21, 2010.
The facility director was interviewed on January 12, 2011. No additional information or documentation was offered for review.
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Plan of Correction
Weekly Supervisory review of the Doctors List will occur by the Medical Liason Officer to insure that Medical Histories are completed upon admission. Discrepancies will be reported to the Program Director in order to utilize Community Resources to rectify the situation.
The Program Director will oversee compliance.
The standard will be in compliance as of March 1,2011.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document a drug and alcohol history per agency policy in one of three client records where required.
The findings include:
Ten client records were reviewed on January 1-12, 2011. Four client records were reviewed as outpatient client records. Per agency policy, the drug and alcohol history is to be completed at intake. The facility did not document a drug and alcohol history per agency policy in client record # 8.
Client # 8 was admitted on November 29, 2011. The drug and alcohol history was to be completed by November 8, 2011. The documented drug and alcohol history was not completed until January 7, 2011.
The facility director was interviewed on January 12, 2011. No additional information or documentation was offered for review.
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Plan of Correction
Before the end of February 2011 the clinician will meet with the Program Director during a regular supervisory session. The Program Director will emphasize the sequence of events outlines in the Gateway Charting Manual available to all clinicians. Furthermore, the function of completing drug and alcohol histories at the time of intake will be discussed with the expectation that this document will serve as the basis for further evaluation.
Compliance will be reviewed during annual performance evaluation and on a monthly basis during chart reviews.
The Program director will insue compliance. The standard will be in full compliance by March 1,2011.
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709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document a personal history per agency policy in one of three client records where required.
The findings include:
Ten client records were reviewed on January 11-12, 2011. Four client records were reviewed as outpatient client records. Per agency policy, the personal history is to be completed at intake. The facility did not document a personal history per agency policy in client record # 8.
Client # 8 was admitted on November 29, 2011. The personal history was to be completed by November 8, 2011. The documented personal history was not completed until January 7, 2011.
The facility director was interviewed on January 12, 2011. No additional information or documentation was offered for review.
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Plan of Correction
Before the end of February 2011 the clinician will meet with the Program Director during a regular supervisory session. The Program Director will emphasize the sequence of events outlines in the Gateway Charting Manual available to all clinicians. Furthermore, the function of completing personal histories at the time of intake will be discussed with the expectation that this document will serve as the basis for further evaluation.
Compliance will be reviewed during annual performance evaluation and on a monthly basis during chart reviews.
The Program director will insue compliance. The standard will be in full compliance by March 1,2011.
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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 on a review of client records and an interview with the facility director, the facility failed to complete the medical, drug and alcohol and personal histories prior to constructing a psychosocial evaluation in one of three client records where required.
The findings include:
Ten client records were reviewed on January 11-12, 2011. Four client records were reviewed as outpatient client records. Psychosocial evaluations were required in three records. Psychosocial evaluations are developed from the information gathered from the client's histories. The facility developed a psychosocial evaluation of the client prior to the completion of the histories in client record # 8.
In client record #8, the psychosocial evaluation was dated November 29, 2010. The medical history was dated December 2, 2010, the drug and alcohol and personal history were dated January 7, 2011.
The facility director was interviewed on January 12, 2011. No additional information or documentation was offered for review.
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Plan of Correction
Before the end of February 2011 the clinician will meet with the Program Director during a regular supervisory session. The Program Director will emphasize the sequence of events outlines in the Gateway Charting Manual available to all clinicians. Furthermore, the function of completing medical,drug and alcohol histories and personal histories will be discussed with the expectation that these documents will serve as the basis for Psychosocial evaluation.
Compliance will be reviewed during annual performance evaluation and on a monthly basis during chart reviews.
The Program director will insue compliance. The standardwill be in full compliance by March 1,2011. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to document a complete client record which included written documentation that was not legible in three of three client records where required.
The findings include:
Ten client records were reviewed on January 11-12, 2011. Four client records were reviewed as outpatient client records. Three client records contained handwritten documentation that was not legible in client records # 7, 8 and 9.
Client # 7 was admitted on December 8, 2010. The progress notes and treatment plan were hand written and were not legible.
Client # 8 was admitted on November 29, 2010. The progress notes and treatment plan were hand written and were not legible.
Client # 9 was admitted on October 25, 2010. The progress notes and treatment plan were hand written and were not legible.
An interview with the facility director on January 12, 2011 confirmed that the handwritten documentation was not legible.
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Plan of Correction
The clinician will meet with the Program Director before the end of February 2011 in a supervisory session. Two methods of improving legibility will be discussed:writing in print format or typing notes. The clinician will exercise a choice. During monthly reviews charts will be checked for legibility.
The Program Director will insure compliance with the standard.
The corrective action will take place by March,1,2011 |
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 the review of client records and an interview with the facility director, the facility failed to document that follow up was completed per agency policy in one of one client record where required.
The findings include:
Ten client records were reviewed on January 11-12, 2011. Four client records were reviewed as outpatient client records. Per agency policy, a follow up attempt is to be completed at 30 days. The facility did not document a follow up attempt in client record #10.
Client # 10 was admitted on April 20, 2010 and discharged on July 22, 2010. Follow up was to be completed by August 22, 2010. There was no documentation that a follow up had been attempted or completed as of January 12, 2010.
The facility director was interviewed on January 12, 2011. No additional information or documentation was offered for review.
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Plan of Correction
Arrangements have been made with the corporate Research Department to provide the necessary followup at the prescribed interval. The Vice President of therapy will oversee the process on a corporate Level.
Locally the Program Director will monitor compliance during monthly chart reviews.Data will be retrieved monthly via a memo requesting data generated by the Program Director
The proceedure is established as of February 1,2011.
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