INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gate House- Marietta 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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in one out of six employee records reviewed.
Employee #1 was hired on October 2, 2017 and was promoted to Project Director on December 5, 2023 and was still in the position as of the date of the inspection. There is no plan for her current position.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 704.11 (b) (1), the following will be implemented:
Beginning 1/10/25, the HR Generalist will ensure that each employee who is due for an annual evaluation also complete an "Annual Training Plan" with their immediate supervisor. The HR Generalist will notify each supervisor of this procedure and ensure its completion.
The direct supervisors will ensure that the staff they supervise complete an annual "Training Needs Assessment" and that the "Annual Training Plan" is completed with the employee during the time that the "Annual Evaluation" is due (hire date).
The HR Generalist will oversee the completion of this procedure when receiving the staff's "Annual Evaluations". She will ensure that each supervisor is submitting the "Annual Eval", "Annual Training Needs Assessment, and "Annual Training Plan". |
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 the Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that 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 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.
Employee #6 was hired as a Counselor on March 6, 2023 and was still in the position at the time of the inspection. Her training was due no later than March 6, 2024; the HIV/AIDS training was completed on December 5, 2023 and the TB/STD training has not been completed.
Employee #7 was hired as a Recovery Specialist on October 31, 2022. Her training was due no later than October 31, 2024; however, the HIV/AIDS training was completed on December 5, 2024 and the TB/STD training has not been completed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 704.11
(c) (1), the following will be
implemented:
Beginning 1/10/2025, the HR
Generalist will continue to give each
new hire a training plan that includes
the requirements of 6 hours of
training for HIV/AIDS and 4 hours of
training for TB/STD. The training
plans will include the due date for
each staff person. 1 year for
counselor assistants, or counselors.
2 years for all other staff.
Each supervisor will ensure that the
staff member completes the required
trainings within the allotted time
frame.
The HR Generalist will oversee the
completion of this procedure as she
receives a copy of all completed
trainings from all staff. In addition,
she will begin receiving annual
training plans that will include the
dates that the staff have completed
the required trainings. |
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 the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors.
Employee #4 was hired as a counselor on May 17, 2023 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2023 through June 30, 2024. Employee # 4's record only document 12 hours of training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 704.11 (f) (2), the following will be implemented:
Beginning 1/10/2025, each counselor will be responsible to register and complete 25 hours of training per fiscal year (July-June). The Clinical Supervisor will ensure that each clinician completes the required amount of training hours per fiscal year. The Clinical Supervisor will monitor each counselors progress towards training hours while meeting monthly for supervision.
The Program Director will oversee this action step during monthly supervision with the Clinical Supervisor. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to complete an annual written individual staff performance evaluation, a copy of which shall be reviewed and signed by the employee. The facility's policy and procedures manual states that an evaluation will be completed 90 days following a promotion.
Employee #1 was promoted to Project Director on December 5, 2023 and was still employed at the time of the inspection. A 90-day written performance evaluation was due no later than March 5, 2024; however, none was completed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.26
(b) (3), the following procedure will
be implemented:
Beginning 1/10/2025, the HR
Generalist will ensure that each
employee receives a 90 day
evaluation following their date of
hire, or 90 days following a
promotion.
All supervisors are
responsible to complete a 90 day
evaluation with the staff they
oversee. The 90 day evaluations are
submitted to the HR Generalist
following the completion of the
documentation.
The Director of Compliance will
oversee the completion of this
procedure during quarterly meeting
with the HR Generalist.
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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 client records, the facility failed to document follow-up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states that the follow-up must be completed 7, 30 and 90 days following discharge.
Client #5 was admitted on May 20, 2024 and discharged on August 18, 2024. A follow-up was due no later than August 25, 2024; however, it was not completed until September 17, 2024.
Client #7 was admitted on August 8, 2024 and was discharged on October 1, 2024. A follow-up was due no later than October 8, 2024; however, it was not completed until October 16, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.53 (a) (11), the following will be implemented:
Beginning 1/10/2025, the Program Assistant will complete and document follow up calls for all clients at 7, 30, and 90 days post discharge. The follow-up contact will be documented in the clients record.
The Program Director will monitor this action step by completing random chart audits, and will meeting with the Program Assistant for monthly supervision.
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