INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center Inc. - Moffett House 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 12, 2010.
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Plan of Correction
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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 records and interview with the facility director and the vice president of human resources, the facility failed to provide documentation of HIV/AIDS and/or TB/STD training in one of five personnel records.
The findings include:
Five personnel records were reviewed on January 4-5, 2010. Five personnel records were required to include documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and/or TB/STD training in personnel record #4.
Employee # 4 is a counselor and was hired September 29, 2008. TB/STD training was due to be completed no later than September 29, 2009. The facility failed to provide documentation of TB/STD training.
The facility director and vice president of human resources confirmed that there was no documentation of HIV/AIDS and TB/STD training in the personnel record of employees # 4. It was also confirmed that employee # 4 has not attended the aforementioned training to date.
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Plan of Correction
Training hours and specific mandatory trainings are listed annually on each employee's Training Plan by the employee and the Clinical Manager. This process will continue, however, the Clinical Manager will also review the training plans quarterly with each employee to make sure necessary trainings are being addressed. In addition, the Director will review this process throughout the year with the Clinical Manager. Staff who are currently not up-to-date with mandatory trainings will attend the necessary trainings as soon as possible. |
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 records and an interview with the facility director and vice president of human resources, the facility failed to document the completion of 25 clock hours of training required annually for counselors in one of two personnel records.
The findings include:
Five personnel records were reviewed on January 4-5, 2010. Two personnel records pertained to counselors. Two personnel records required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 4.
Employee # 4 was hired on September 29, 2008. The facility training year is from January to December. Employee # 4 completed 13.5 clock hours of annual training from January through December 2009.
The facility director and vice president of human resources confirmed that employee # 4 completed 13.5 clock hours of annual training from January through December 2009.
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Plan of Correction
Employee #4 was listed as an employee of the Moffett House which was incorrect. Efforts are currently being made in conjunction with Human Resources to remove him from the Moffett House roster. While that process is occuring, Human Resources will be responsible to ensure employee #4 participates in the appropriate number of training hours. In the future, the Director will review the staffing forms completed by the Human Resources Department before licensing visits for accuracy. In addition, the Clinical Manager at the Moffett House will review all training hours quarterly to ensure Moffett House staff have adequate hours and mandatory trainings during the appropriate time periods.
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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
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 one of one client records.
The findings include:
Six client records were reviewed on January 8 and 19, 2010. One client reviewed was terminated and documentation was required to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 2.
In client record # 2, the client was involuntarily terminated from the project on May 19, 2009. There was no documentation of written notification to the client as of January 19, 2010.
The reasons for client termination were documented in the client record, however, there is no documentation that the client is provided this information via client signature or mailing. The facility director via interview on January 19, 2010 confirmed that a termination notice is not mailed to the client nor is a copy provided at the time of discharge.
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Plan of Correction
Gateway is currently updating its Termination of Treatment form to include an area to specify whether or not the patient received a copy of the form.
From this point on, all Involuntarily Discharged patient charts will be reviewed by the Clinical Manager. If the Termination of Treatment form is not completed, the Clinical Manager will complete the form, mail it to the last known address and document such action. |