INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted on January 23, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel training records, the facility failed to document individual training plans by December of each year, as per facility policy, in five of six personnel records.
The findings include:
Eight personnel training records were reviewed on January 3 - 5, 2012. Eight personnel training records were reviewed for individual training plans. Six personnel training records were reviewed for compliance with the completion of the training plans due December 2010. 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, 4, 6 and 7. Training plans for personnel records 1, 2, 4 and 6 were completed between January 26 and March 11, 2011. The last documented training plan in personnel record # 7 was dated January 27, 2009.
The human resources director was interviewed throughout the licensing process and confirmed the findings. The facility director was interviewed on January 23, 2012 and confirmed the findings.
|
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 assists 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. |
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.
|
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 one of three personnel training records.
The findings include:
Eight personnel training records were reviewed on January 3 - 5, 2012. Three personnel training records were reviewed for documentation of communicable disease training. The facility failed to provide documentation of TB/STD training in personnel training records # 6 .
Employee # 6 is a counselor technician and was hired on September 14, 2009. TB/STD training was due to be completed no later than September 14, 2011. The facility failed to provide documentation of HIV/AIDS training for employee # 6.
The human resources director was interviewed throughout the licensing process and confirmed the findings. The facility director was interviewed on January 23, 2012 and confirmed the findings.
|
Plan of Correction
The clinical manager is to review 2012 training plans with employee #6 and all facility staff. The manager will identify dates of requred training(s) for employee #6 to attend. Upon completion of training plan for employee #6, clinical manager & Gateway Human resources will recieve copy of certificate.
Employee #6 and other staff will be required to submit certificate of training to Gateway's human resources to be placed in personnel file and placed on the training data base. Employee #6 and other facility staff is to give Clinical manager a copy of certificate to be kept on file at facility. The clinical manager will review employee #6 and all staff training plan during monthly supervision.
The Director of facilty will review status of completion of staff trainings with clinical manager on a semi-annual basis. |
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.
|
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 one of one personnel training record.
The findings include:
Eight personnel training records were reviewed on January 3 - 5, 2012. One personnel training record pertained to a counselor. One personnel training record required documentation of 25 clock hours of annual training. The training year reviewed was from January 1 - December 31, 2011. The facility failed to document 25 clock hours of annual training in personnel training record # 4.
Employee # 4 is a counselor and was hired on November 29, 1994. Personnel training record # 4 included documentation of only 16 clock hours of annual training.
The human resources director was interviewed throughout the licensing process and confirmed the findings. The facility director was interviewed on January 23, 2012 and confirmed the findings.
|
Plan of Correction
The Clinical manager will meet with employee #4 to review 2012 training plan. The clinical manager will implement the follwing steps to ensure of staff meeting requred training hours. Upon completion of trainings the employee is to submit certificates to Gateway's Human Resources to be placed in personnel file and placed on Gateway's training data base. The employee is to give copy of certificate to clinical manager to be placed in file at facility. The clinical manager will review status of training plan with employee during monthly supervision.
The Director will review completion of training plans with Clinical manager on a semi-annual basis. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
Fire drill logs were reviewed on January 23, 2012. Documentation of a fire drill conducted during sleeping hours is required once every six months. The fire drill logs were reviewed from February to December 2011. During that time frame, the facility documented only one fire drill during sleeping hours on February 26, 2011.
An interview with the facility director on January 23, 2012 confirmed the findings.
|
Plan of Correction
The facility ramdomly conduct fire drills on a monthly basis. The fire drills are conducted during different times of day and week. The fire drill is conducted by all staff of facility. The overnight fire drill will randomly be conducted. The clinical manager will oversee completion of fire drills.
The overnights fire drills will be completed a least once every six months. |
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of four client records.
The findings include:
Eight client records were reviewed on January 9 and 23, 2012. Four client records were reviewed for compliance with the requirement to obtain an informed and voluntary consent to release information from the client record. The facility accessed the Internet site of a funding entity to confirm the client's current insurance coverage. Prior to releasing client information to this funding entity, the facility failed to document an informed and voluntary consent to release information from the client in client records # 6 and 7.
The facility director confirmed the findings during an interview on January 23, 2012.
|
Plan of Correction
The Clinical manager of facility does all interviews of perspective client requesting admission into facilty. Prior to interview the clinical manager will have a completed consent authorizating facility to check client financial eligibilty. The consent will be faxed to referring agency to be signed by client and witness by referring agency staff. The consent will then be faxed back to facilty and kept in clients record. |
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.
|
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 three of three client records.
The findings include:
Eight client records were reviewed on January 9 and 23, 2012. Three client records were required to include documentation that the client was notified 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 records # 2, 3 and 5.
In client record # 2, the client was admitted into treatment on May 2, 2011 and was involuntarily terminated from the project on June 7, 2011. There was no documentation of written notification to the client at the time of the licensing inspection.
In client record # 3, the client was admitted into treatment on April 1, 2011 and was involuntarily terminated from the project on June 3, 2011. There was no documentation of written notification to the client at the time of the licensing inspection.
In client record # 5, the client was admitted into treatment on June 21, 2011 and was involuntarily terminated from the project on October 25, 2011. There was no documentation of written notification to the client at the time of the licensing inspection.
The facility director was interviewed on January 23 , 2012. The facility director confirmed the findings.
|
Plan of Correction
When a client is being involuntarily terminated from treatment. The initial process is to have client sign a termination of treatment form. The termination of treatment form will explain reason(s) for the involuntary termination of treatment.
If staff is unable to or client refuses to sign termination of treatment form a letter will be sent to the client last known address. The letter will explain reason(s) for involuntary termination of treatment and explain the appeals process of facility.
The letter will be sent out within forty-eight hours post discharge from facility. A copy of letter will be place in client chart. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to document psychosocial evaluations which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in two of three client records.
The findings include:
Eight client records were reviewed on January 9 and 23, 2012. Three client records were reviewed for the completion of a psychosocial evaluation. The psychosocial evaluations were not evaluative in client records # 6 and 7.
Client # 6 was admitted on December 30, 2011. The psychosocial evaluation, completed on December 30, 2011, did not document an evaluation based on the historical information provided by the client. The client's personal history was not completed until January 1, 2012. The information documented for the client's support systems and coping mechanisms were client reported.
Client # 7 was admitted on October 17, 2011. The psychosocial evaluation, completed on October 17, 2011, did not include documentation of an evaluation based on the historical information provided by the client. The client's personal history was not completed until October 20, 2011. The information documented for the client's support systems and coping mechanisms were client reported.
An interview with the facility director and clinical supervisor conducted on January 23, 2012, acknowledged the findings.
This is a repeat citation from the January 12, 2011 licensing inspection.
|
Plan of Correction
The Clinical manager will meet with Staff regarding documentation issues. Manager and staff will participate in facility training reviewing documentations. The clinical manager will do regular audit of of charts and review in with staff in monthly supervision.
The Director will do monthly random audit of charts ensuring documentation is implemented. The Director will discuss out come staff and clinical manager |
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.
|
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 one of three client records.
The findings include:
Eight client records were reviewed on January 9 and 23, 2012. Five client records were closed. Three of the closed client records 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 record # 3.
Client # 3 was admitted into treatment on April 1, 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 23, 2012.
The facility director was interviewed on January 23, 2012 and confirmed the findings.
This is a repeat citation from the January 12, 2011 licensing inspection.
|
Plan of Correction
The facility is to continue to follow Gateway's follow-up policy. Upon a clients discharge from treatment a follow-up will be completed with in a six month time frame.
Once a client is discharged form facility the clinical manager will contact director of research & development in forming of clients discharge from treatment. this will ensure that appropiate data is submitted.
The director will meet on quarterly basis with clinical manager and director of research department to review the transferring and timeliness of information of follow-up process among sites. This will ensure the action plan is being implemented. |