INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 5-6, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
|
Plan of Correction
|
709.62(a)(4) LICENSURE Criteria - Discharge/termination
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
|
Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against medical advice in one of one applicable record.
The facility's policy and procedure manual states the client ' s emergency contact will be notified no later than 12 hours of a patient leaving against medical advice.
Client #2 was admitted to the detox level of care on January 23, 2024, and discharged on January 25, 2024.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Program Director will be responsible for training all clinical staff about the written plan to call all emergency contacts for involuntary/ama discharges within 12 hours of discharge by 9/6/2024.
Clinical managers on duty when a patient leaves treatment involuntarily or ama will be responsible for making the phone to the emergency contact immediately to inform them of the discharge.
If a clinical manager is not on site, the lead clinical therapist will be responsible for making the phone call.
Program director will audit all early discharge charts to ensure that the emergency contact was notified when appropriate and required within 12 hours. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to develop an individual treatment and rehabilitation plan with the client in five of seven records.
Client #16 was admitted to the outpatient level of care on November 6, 2023 and was discharged January 18, 2024. Client #16 had a comprehensive treatment plan dated November 8, 2023, but there was no indication that the treatment plan was developed with the client.
Client #17 was admitted to the outpatient level of care on January 29, 2024 and was discharged March 4, 2024. Client #17 had a comprehensive treatment plan dated February 5, 2024, but there was no indication that the treatment plan was developed with the client.
Client #18 was admitted to the outpatient level of care on March 26, 2024 and was discharged May 6, 2024. Client #18 had a comprehensive treatment plan dated April 1, 2024, but there was no indication that the treatment plan was developed with the client.
Client #19 was admitted to the outpatient level of care on April 10, 2024 and was active at the time of review. Client #19 had a comprehensive treatment plan dated April 16, 2024, but there was no indication that the treatment plan was developed with the client.
Client #21 was admitted to the outpatient level of care on May 14, 2024 and was active at the time of review. Client #21 had a comprehensive treatment plan dated May 20, 2024, but there was no indication that the treatment plan was developed with the client.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
It shall be the responsibility of the Program Manager to train program staff on the proper completion of the comprehensive treatment plan including patients participating in the treatment planning session and signing their treatment plan by September 6, 2024.
The Program Manager shall be responsible for verifying accurate completion of the releases by completing random chart supervision in 10% of the charts monthly.
|