INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10 - 12, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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 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 each year, as per facility policy, in twenty-seven of thirty-three personnel records.
The findings include:
Forty-seven personnel training records were reviewed on January 3 - 5, 2012. Thirty-three 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, 4, 5, 6, 7, 8, 9, 10, 11, 16, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 and 36. Training plans for these employees were completed between January 25 and February 11, 2011.
Personnel training records # 12 and 17 pertained to new employees and did not include documentation of an individual training plan for the 2011 training year.
Employee # 12 was hired on August 15, 2011. Personnel training record # 12 did not not include documentation of an individual training plan.
Employee # 17 was hired on May 2, 2011. Personnel training record # 17 did not include documentation of an individual training plan.
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 practices and processes. The 2012 training year will therefore be from February 1, 2012 to January 31, 2013. The change also specificly states that supervisory staff will develop an annual training plan for each of the employees in their department. The calendar includes individual training needs, the topics and number of hours of training required by various outside sources, licensing and regulatory groups, and internal and external training events. The Human Resources staff assist the supervisors in the development of these training calendars.
The 2012 calendars were forwarded to the supervisory staff on 1/23/2012 and are due by 2/1/2012.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report form, the facility failed to provide documentation of communicable disease training in thirteen of seventeen personnel training records.
The findings include:
Forty-seven personnel training records were reviewed on January 3 - 5, 2012. Seventeen personnel training records were reviewed for documentation of communicable disease training. The facility failed to provide documentation of HIV/AIDS and TB/STD training in personnel training records # 40 and 47. The facility failed to provide documentation of HIV/AIDS training in personnel training records # 35, 38 and 46. The facility failed to provide documentation of TB/STD training in personnel records # 36, 37, 39, 41, 42, 43, 44 and 45.
Employee # 35 is a counselor and was hired on November 22, 2010. HIV/AIDS training was due to be completed no later than November 22, 2011. The facility failed to provide documentation of HIV/AIDS training for employee # 35.
Employee # 36 is a counselor and was hired on March 24, 2008. TB/STD training was due to be completed no later than March 24, 2009. The facility failed to provide documentation of TB/STD training for employee # 36.
Employee # 37 is support staff and was hired January 5, 2009. TB/STD training was due to be completed no later than January 5, 2011. The facility failed to provide documentation of TB/STD training for employee # 37.
Employee # 38 is support staff and was hired October 22, 2007. HIV/AIDS training was due to be completed no later than October 22, 2009. The facility failed to provide documentation of HIV/AIDS training for employee # 38.
Employee # 39 is support staff and was hired September 5, 2006. TB/STD training was due to be completed no later than September 5, 2008. The facility failed to provide documentation of TB/STD training for employee # 39.
Employee # 40 is support staff and was hired September 29, 2008. HIV/AIDS and TB/STD training was due to be completed no later than September 29, 2010. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 40.
Employee # 41 is support staff and was hired January 21, 2008. TB/STD training was due to be completed no later than January 21, 2010. The facility failed to provide documentation of TB/STD training for employee # 41.
Employee # 42 is support staff and was hired June 22, 2009. TB/STD training was due to be completed no later than June 22, 2011. The facility failed to provide documentation of TB/STD training for employee # 42.
Employee # 43 is support staff and was hired May 25, 2004. TB/STD training was due to be completed no later than May 25, 2006. The facility failed to provide documentation of TB/STD training for employee # 43.
Employee # 44 is support staff and was hired January 12, 2009. TB/STD training was due to be completed no later than January 12, 2011. The facility failed to provide documentation of TB/STD training for employee # 44.
Employee # 45 is support staff and was hired October 15, 2007. TB/STD training was due to be completed no later than October 15, 2009. The facility failed to provide documentation of TB/STD training for employee # 45.
Employee # 46 is support staff and was hired July 13, 2009. HIV/AIDS training was due to be completed no later than July 13, 2011. The facility failed to provide documentation of HIV/AIDS training for employee # 46.
Employee # 47 is support staff and was hired November 9, 2009. HIV/AIDS and TB/STD training was due to be completed no later than November 9, 2011. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 47.
The facility director and human resources director were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the April 16 -18, 2007, January 14 - January 16, 2008, January 8 - 9, 2009, January 11 - 12, 2010 and December 20 - 21, 2010 inspections.
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Plan of Correction
Individual staff who were out of compliance for HIV/AIDS and/or TB/STD training will be required to attend training no later than 5/18/2012. Staff who attended the required training but who did not submit their training certificates will be required to submit the certificate and evaluation to the HR Department no later than 2/17/2012. Clinical Managers and Supervisors will monitor for compliance. |
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
Based on a review of personnel training records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in eight of fifteen personnel training records.
The findings include:
Forty-seven personnel training records were reviewed on January 3 - 5, 2012. Twenty-one personnel training records pertained to counselors. Fifteen personnel training records required documentation of 25 clock hours of annual training. Six personnel training records pertained to newly hired counselors. The training year is from January 1 - December 31, 2011. The facility failed to document 25 clock hours of annual training in personnel training records # 23, 26, 27, 30, 31, 33, 34 and 36.
Employee # 23 is a counselor and was hired on September 13, 1995. Personnel training record # 23 only included documentation of 3.25 clock hours of annual training.
Employee # 26 is a counselor and was hired on January 20, 1990. Personnel training record # 26 only included documentation of 12 clock hours of annual training.
Employee # 27 is a counselor and was hired on October 18, 1999. Personnel training record # 27 only included documentation of 15.5 clock hours of annual training.
Employee # 30 is a counselor and was hired on October 5, 2009. Personnel training record # 30 only included documentation of 16.25 clock hours of annual training.
Employee # 31 is a counselor and was hired on September 21, 2009. Personnel training record # 31 only included documentation of 6.75 clock hours of annual training.
Employee # 33 is a counselor and was hired on November 17, 2003. Personnel training record # 33 only included documentation of 10 clock hours of annual training.
Employee # 34 is a counselor and was hired on January 21, 2008. Personnel training record # 34 only included documentation of 16 clock hours of annual training.
Employee # 36 is a counselor and was hired on March 24, 2008. Personnel training record # 36 only included documentation of 14.5 clock hours of annual training.
The human resources director and facility director were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Counselors are required to complete 25 hours of documented training each calendar year. Several of the counselors cited had completed the training but did not submit documentation to the Human Resources office. This has been corrected. The other counselors have scheduled training to correct the deficiency. This training will be completed no later than 5/18/12. |
709.83(a)(1) 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:
(1) Consent forms.
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Observations
Based on a review of client records, the facility failed to document a follow-up consent form in four of seven partial hospitalization client records.
The findings include:
Thirty-one client records were reviewed on January 10 - 12, 2012. Seven client records pertained to the partial hospitalization activity. Per facility policy, follow-up consents will be completed during the intake process. The facility failed to document follow-up consent forms in client records # 18, 19, 21 and 24.
Client # 18 was admitted into treatment on March 14, 2011 and discharged on May 3, 2011. Client record # 18 did not include a consent to follow-up form.
Client # 19 was admitted into treatment on May 24, 2011 and discharged on June 14, 2011. Client record # 19 did not include a consent to follow-up form.
Client # 21 was admitted into treatment on December 1, 2010 and discharged on March 7, 2011. Client record # 21 did not include a consent to follow-up form.
Client # 24 was admitted into treatment on December 19, 2011. Client record # 24 did not include a consent to follow-up form.
The facility director and clinical supervisors were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
Upon admission to the facility the Admissions Officer is required to have all patients sign a consent to follow up form either agreeing or refusing follow up. The form has been placed in every admission packet and the admissions staff has been trained on completing the forms. The problem has been corrected. The Admissions Office Manager will audit charts to ensure continuing compliance. |
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 the facility's policy and procedure manual and client records, the facility failed to document follow-up information in three of four partial hospitalization client records.
The findings include:
Thirty-one client records were reviewed on January 10 - 12, 2012. Seven client records pertained to the partial hospitalization activity. Four client records were closed and 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 records # 18, 19 and 21.
Client # 18 was admitted into treatment on March 14, 2011 and discharged on May 3, 2011. A follow-up attempt was due to be completed no later than November 3, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
Client # 19 was admitted into treatment on May 24, 2011 and discharged on June 14, 2011. A follow-up attempt was due to be completed no later than December 14, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
Client # 21 was admitted into treatment on December 1, 2010 and discharged on March 7, 2011. A follow-up attempt was due to be completed no later than September 7, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
The facility director and clinical supervisors were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Consents for followup are now completed at the time of admission. The admission staff make a copy for the patient and submit another copy to the Therapy Office. The administrative assistants in the Therapy Office forward the consents twice each week to the Director of Research and Evaluation. The Research Associates complete the followup calls and send the documentation to the Medical Records department for filing. The original consent remains in the chart.
The Admissions Department Manager and the Medical Records Manager will audit charts to make certain that all charts meet expectations for follow-up. |
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
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in four of five client records.
The findings include:
Thirty-one client records were reviewed on January 10 -12, 2012. Five clients were involuntarily terminated from treatment at the project, The project was required to provide these clients with written notification of this decision. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client records # 1, 3, 11 and 21.
Client # 1 was admitted into treatment on June 27, 2011 and was involuntarily terminated from the project on June 29, 2011. The facility failed to document that client # 1 was notified, in writing, of the decision to involuntarily terminate the client's treatment at the project.
Client # 3 was admitted into treatment on July 25, 2011 and was involuntarily terminated from the project on July 27, 2011. The facility failed to document that client # 3 was notified, in writing, of the decision to involuntarily terminate the client's treatment at the project.
Client # 11 was admitted into treatment on May 23, 2011 and was involuntarily terminated from the project on May 29, 2011. The facility failed to document that client # 11 was notified, in writing, of the decision to involuntarily terminate the client's treatment at the project.
Client # 21 was admitted into treatment on December 1, 2010 and was involuntarily terminated from the project on March 7, 2011. The facility failed to document that client # 21 was notified, in writing, of the decision to involuntarily terminate the client's treatment at the project.
The facility director and clinical supervisors were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the December 20 - 21, 2010 licensing inspection.
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Plan of Correction
Termination of Treatment forms are issued to all patients receiving an Involuntary Discharge. The Detox Therapy and Nursing Staff are responsible for this process on the Detox Unit. The Detox Clinical Manager will review all Involuntary Discharge cases on the Detox Unit to ensure that this process is being completed. If a Termination of Treatment form has not been completed, the Detox Clinical Manager will coordinate completing and mailing the form to the patient's address and documenting that such action took place. |
709.63(a)(1) LICENSURE Consent Forms
709.63. 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:
(1) Consent forms.
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Observations
Based on a review of client records, the facility failed to document a follow-up consent form in seven of seven short-term detoxification client records.
The findings include:
Thirty-one client records were reviewed on January 10 - 12, 2012. Seven client records pertained to the short-term detoxification activity. Per facility policy, follow-up consents will be completed during the intake process. The facility failed to document follow-up consent forms in client records # 1, 2, 3, 4, 5, 6 and 7.
Client # 1 was admitted into treatment on July 27, 2011 and discharged on July 29, 2011. Client record # 1 did not include a consent to follow-up form.
Client # 2 was admitted into treatment on June 14, 2011 and discharged on June 14, 2011. Client record # 2 did not include a consent to follow-up form.
Client # 3 was admitted into treatment on July 25, 2011 and discharged on July 29, 2011. Client record # 3 did not include a consent to follow-up form.
Client # 4 was admitted into treatment on May 24, 2011 and discharged on May 24, 2011. Client record # 4 did not include a consent to follow-up form.
Client # 5 was admitted into treatment on January 6, 2012. Client record # 5 did not include a consent to follow-up form.
Client # 6 was admitted into treatment on January 7, 2012. Client record # 6 did not include a consent to follow-up form.
Client # 7 was admitted into treatment on January 6, 2012. Client record # 7 did not include a consent to follow-up form.
The facility director and detox clinical supervisor were interviewed throughout the licensing process and confirmed the findings.
This is a repeat citation from the December 20 - 21, 2010 licensing inspection.
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Plan of Correction
Upon admission to the facility the Admissions Officer is required to have all patients sign a consent to follow up form either agreeing or refusing follow up. The form has been placed in every admission packet and the admissions staff has been trained on completing the forms. The problem has been corrected. The Admissions Office Manager will audit charts to ensure continuing compliance. |
709.63(a)(7) LICENSURE Discharge summary
709.63. 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:
(7) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary within one week of discharge, as per facility policy, in three of four short-term detoxification client records.
The findings include:
Thirty-one client records were reviewed on January 10 - 12, 2012. Seven client records pertained to the short-term detoxification activity. Four of these records were closed and required documentation of a discharge summary. Per facility policy, a discharge summary will be documented within one week of discharge. The facility failed to document a discharge summary within one week of discharge in client records # 2, 3 and 4.
Client # 2 was admitted into treatment on June 14, 2011 and discharged on June 14, 2011. A discharge summary was due to be completed no later than June 21, 2011. The discharge summary was not documented until July 21, 2011.
Client # 3 was admitted into treatment on July 25, 2011 and discharged on July 29, 2011. A discharge summary was due to be completed no later than August 5, 2011. The discharge summary was not documented until August 7, 2011.
Client # 4 was admitted into treatment on May 24, 2011 and discharged on May 24, 2011. A discharge summary was due to be completed no later than May 31, 2011. The discharge summary was not documented until June 30, 2011.
The detox clinical supervisor was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
Discharge Summaries are to be completed within 7 days of discharge from Gateway. The Detox Therapy Staff are responsible for this process. The Detox Clinical Manager will review all discharges from Detox on a weekly basis to ensure that Discharge Summaries are completed in the appropriate timeframe.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) 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 three of three short term detoxification client records.
The findings include:
Thirty-one client records were reviewed on January 10 - 12, 2012. Seven client records pertained to the short term detoxification activity. Four client records were closed. Three of the closed client records required documentation of a follow-up attempt. One client 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 records # 1, 2 and 4.
Client # 1 was admitted into treatment on June 27, 2011 and discharged on June 29, 2011. A follow-up attempt was due to be completed no later than December 29, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
Client # 2 was admitted into treatment on June 14, 2011 and discharged on June 14, 2011. A follow-up attempt was due to be completed no later than December 14, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
Client # 4 was admitted into treatment on May 24, 2011 and discharged on May 24, 2011. A follow-up attempt was due to be completed no later than November 24, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
The facility director and detox clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the December 20 - December 21, 2010 licensing inspection.
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Plan of Correction
Consents for followup are now completed at the time of admission. The admission staff make a copy for the patient and submit another copy to the Therapy Office. The administrative assistants in the Therapy Office forward the consents twice each week to the Director of Research and Evaluation. The Research Associates complete the followup calls and send the documentation to the Medical Records department for filing. The original consent remains in the chart. The Admissions Office Manager and Clinical Managers will audit charts for compliance |
709.53(a)(1) LICENSURE Consent Forms
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:
(1) Consent forms.
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Observations
Based on a review of client records, the facility failed to document a follow-up consent form in eight of ten inpatient client records.
The findings include:
Thirty-one client records were reviewed on January 10 - 12, 2012. Ten client records pertained to the inpatient non-hospital activity. Per facility policy, follow-up consents will be completed during the intake process. The facility failed to document follow-up consent forms in client records # 8, 10, 11, 12, 13, 14, 15 and 17.
Client # 8 was admitted into treatment on March 23, 2011 and discharged on April 11, 2011. Client record # 8 did not include a consent to follow-up form.
Client # 10 was admitted into treatment on May 22, 2011 and discharged on June 3, 2011. Client record # 10 did not include a consent to follow-up form.
Client # 11 was admitted into treatment on May 23, 2011 and discharged on May 29, 2011. Client record # 11 did not include a consent to follow-up form.
Client # 12 was admitted into treatment on December 15, 2011. Client record # 12 did not include a consent to follow-up form.
Client # 13 was admitted into treatment on December 29, 2011. Client record # 13 did not include a consent to follow-up form.
Client # 14 was admitted into treatment on December 16, 2011. Client record # 14 did not include a consent to follow-up form.
Client # 15 was admitted into treatment on December 27, 2011. Client record # 15 did not include a consent to follow-up form.
Client # 17 was admitted into treatment on December 17, 2011. Client record # 17 did not include a consent to follow-up form.
The facility director and inpatient clinical supervisors were interviewed throughout the licensing process and confirmed the findings.
This is a repeat citation from the December 20 - 21, 2010 licensing inspection.
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Plan of Correction
Upon admission to the facility the Admissions Officer is required to have all patients sign a consent to follow up form either agreeing or refusing follow up. The form has been placed in every admission packet and the admissions staff has been trained on completing the forms. The problem has been corrected. The Admissions Office Manager will audit charts to ensure continuing 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 a review of the facility's policy and procedure manual and client records, the facility failed to document follow-up information in three of four inpatient client records.
The findings include:
Thirty-one client records were reviewed on January 10 - 12, 2012. Ten client records pertained to the inpatient non-hospital activity. Four client records were closed and 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 records # 8, 10 and 11.
Client # 8 was admitted into treatment on March 23, 2011 and discharged on April 11, 2011. A follow-up attempt was due to be completed no later than October 11, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
Client # 10 was admitted into treatment on May 22, 2011 and discharged on June 3, 2011. A follow-up attempt was due to be completed no later than December 3, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
Client # 11 was admitted into treatment on May 23, 2011 and discharged on May 29, 2011. A follow-up attempt was due to be completed no later than November 29, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
The facility director and inpatient clinical supervisors were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the January 11 - 12, 2010 and December 20 - December 21, 2010 licensing inspections.
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Plan of Correction
Consents for followup are now completed at the time of admission. The admission staff make a copy for the patient and submit another copy to the Therapy Office. The administrative assistants in the Therapy Office forward the consents twice each week to the Director of Research and Evaluation. The Research Associates complete the followup calls and send the documentation to the Medical Records department for filing. The original consent remains in the chart. The Admissions Office Manager and Clinical Managers will audit charts for compliance. |
709.93(a)(1) 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:
(1) Consent forms.
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Observations
Based on a review of client records, the facility failed to document a follow-up consent form in five of six outpatient client records.
The findings include:
Thirty-one client records were reviewed on January 10 - 12, 2012. Seven client records pertained to the outpatient activity. One client record was from a timeframe outside of the current licensing inspection. Per facility policy, follow-up consents will be completed during the intake process. The facility failed to document follow-up consent forms in client records # 26, 27, 29, 30 and 31.
Client # 26 was admitted into treatment on May 19, 2011 and discharged on June 6, 2011. Client record # 26 did not include a consent to follow-up form.
Client # 27 was admitted into treatment on April 13, 2011 and discharged on May 25, 2011. Client record # 27 did not include a consent to follow-up form.
Client # 29 was admitted into treatment on September 23, 2011. Client record # 29 did not include a consent to follow-up form.
Client # 30 was admitted into treatment on August 24, 2011. Client record # 30 did not include a consent to follow-up form.
Client # 31 was admitted into treatment on September 26, 2011. Client record # 31 did not include a consent to follow-up form.
The facility director and clinical supervisors were interviewed throughout the licensing process and confirmed the findings.
This is a repeat citation from the December 20 - 21, 2010 licensing inspection.
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Plan of Correction
Upon admission to the facility the Admissions Officer is required to have all patients sign a consent to follow up form either agreeing or refusing follow up. The form has been placed in every admission packet and the admissions staff has been trained on completing the forms. The problem has been corrected. The Admissions Office Manager will audit charts to ensure continuing 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 four of four outpatient client records.
The findings include:
Thirty-one client records were reviewed on January 10 - 12, 2012. Seven client records pertained to the outpatient activity. Four client records were closed and 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 records # 25, 26, 27 and 28
Client # 25 was admitted into treatment on September 1, 2010 and discharged on April 8, 2011. A follow-up attempt was due to be completed no later than October 8, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
Client # 26 was admitted into treatment on May 19, 2011 and discharged on June 8, 2011. A follow-up attempt was due to be completed no later than December 8, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
Client # 27 was admitted into treatment on April 13, 2011 and discharged on May 25, 2011. A follow-up attempt was due to be completed no later than November 25, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
Client # 28 was admitted into treatment on April 19, 2011 and discharged on June 21, 2011. A follow-up attempt was due to be completed no later than December 21, 2011. The facility failed to provide documentation of a follow-up attempt as of January 10 - 12, 2012.
The facility director and clinical supervisors were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the December 20 - December 21, 2010 licensing inspection.
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Plan of Correction
Consents for followup are now completed at the time of admission. The admission staff make a copy for the patient and submit another copy to the Therapy Office. The administrative assistants in the Therapy Office forward the consents twice each week to the Director of Research and Evaluation. The Research Associates complete the followup calls and send the documentation to the Medical Records department for filing. The original consent remains in the chart. The Admissions Office Manager and Clinical Managers will audit charts for compliance |