INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 23, 2012 licensure renewal inspection. The follow-up inspection was conducted on August 21, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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:
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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, the facility failed to provide documentation of communicable disease training in one of one personnel records.
The findings include:
Four personnel records were reviewed on August 21, 2012. One personnel record was reviewed for the purpose of verifying the completion of communicable disease training. Personnel record #4 did not include documentation of the completion of communicable disease training.
Employee #4 was hired as a counselor technician on September 14, 2009. TB/STD training was due to be completed by September 14, 2011. At the time of the inspection, August 21, 2012, employee #4 has not yet completed the TB/STD training.
An interview with the clinical supervisor took place on August 21, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
The clinical manager met with employee #4 regarding mandatory (TB/STD) training. Employee #4 is registetred for communible diseases (TB/STD) training on 9-21-12. Upon completion of training employee #4 will submit copy of certificate to facility clinical manager and Gateway's Human Resource deppartment to be plcaed in their file.
The Clinical Manager will monitor all staff required trainings with assistance from the Human Resources training data base and reviewing training plans with staff during supervision.
The Director of facility will review training plans with clinical manager on semi-annual basis to ensure that mandatory trainings are being completed by staff in required time frames.
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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
The time period for observation is insufficient to determine compliance as of August 21, 2012. The deficiency from the licensing inspection conducted January 23, 2012 is as follows:
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.
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Plan of Correction
The Clinical manager will met 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.
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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 document that it notified the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in four of four client records.
The findings include:
Eleven client records were reviewed on August 21, 2012. Five of the clients reviewed were involuntarily terminated from treatment at the project and required written notification of the termination. Client records # 7, 8, 9, and 11 did not include documentation that the client was provided notification, in writing, of the decision to involuntarily terminate the client's treatment at the project.
Client #7 was admitted on June 28, 2012 and terminated from treatment on July 4, 2012. There was no documentation that the client was provided notification of the termination in writing.
Client #8 was admitted on April 16, 2012 and terminated from treatment on July 9, 2012. There was no documentation that the client was provided notification of the termination in writing.
Client #9 was admitted on April 23, 2012 and terminated from treatment on July 13, 2012. There was no documentation that the client was provided notification of the termination in writing.
Client #11 was admitted on July 11, 2012 and terminated from treatment on July 21, 2012. There was no documentation that the client was provided notification of the termination in writing.
An interview with the clinical supervisor took place on August 21, 2012 at which time the aforementioned information was confirmed.
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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.
The Clinical manager will meet with clinical staff reviewing termination of treatment process. The Clinical manager will review discharge charts ensuring that termination of treatment process is being completed. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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, the facility failed to document 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 four of six client records.
The findings include:
Six active client records were reviewed on August 21, 2012. All six client records were required to include documentation of a psychosocial evaluation based on historical information provided by the client. Client records # 2, 3, 4 and 5 did not include documentation of a psychosocial evaluation based on historical information provided by the client.
Client #2 was admitted on April 30, 2012. The historical information was collected on May 2, 2012. The psychosocial evaluation was completed on April 30, 2012, prior to the collection of historical information.
Client #3 was admitted on April 9, 2012. The historical information was collected on March 26, 2012. There was no documentation of a psychosocial evaluation in client record #3.
Client #4 was admitted on April 16, 2012. The historical information was collected on April 18, 2012. The psychosocial evaluation was completed on April 16, 2012, prior to the collection of historical information.
Client #5 was admitted on April 3, 2012. The historical information was collected on April 5, 2012. The psychosocial evaluation was completed on April 3, 2012, prior to the collection of historical information.
An interview with the clinical supervisor took place on August 21, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
On May 21, 2012 Gateway tranisitioned from paper charts to Electronic Records. The electronic record require that clinical staff gather historical information from clients prior to completing psychosocial evaluation.
The clinical manager will regularly audit electronic records. |
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
The time period for observation is insufficient to determine compliance as of August 21, 2012. The deficiency from the licensing inspection conducted January 23, 2012 is as follows:
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.
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Plan of Correction
Moffett House will follow Gateway's Follow-up pocily. Once a client is discharged from treatment a follow-up will be complete with in a six month time frame.
On May 21, 2012 Gateway transitioned from paper charts to electronic records. The electronic record will assist in ensuring a client follow-up is completed in timely manner.
The clinical manager will contact Director of Research & Development informing of client's discharge from facility. The Director of Moffett will review the timeliness and tranferring of follow-up information between Clinical manager and Director of research & development. |