INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 7-11, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gateway Erie 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 and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #9 was hired as a counselor on June 7, 2021 and was still employed in that position. Employee #9 was due to have the communicable disease trainings no later than June 7, 2022. Employee #9 received HIV/AIDS training on August 2, 2022 and TB/STD training on August 1, 2022.
This is a repeat citation from October 24, 2019, August 28, 2020, and November 4, 2021 1icensing inspections.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All relevant staff will review the DDAP 704.11 (c )(1) regulation by November 16, 2022. The new hire orientation process will be amended to include HIV/AIDS and TB/STD training. The training coordinator will be responsible for coordinating the new hire orientation training period and the communicable disease training. The training will be completed within the first 3 days of hire before the new employee will report to their job duties. The training coordinator is responsible for communicating the completion of these trainings to the responsible clinical manager and director after each new hire class.
This new process will be implemented by November 21, 2022. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms identified as group rooms A, B, C and D.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway Rehabilitation Center will request the waiver to allow cameras in the group rooms by December 1, 2022.
If the waiver is denied by DDAP, Gateway Rehabilitation Center will remove the cameras in the group rooms within 5 business days of receiving the denial. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
The facility failed to comply with plans of corrections approved by the department. The facility received citations for Mandatory Communicable Disease training during the annual licensing inspections on October 24, 2019, August 28, 2020 and November 4, 2021. Plans of corrections to gain compliance were completed by facility staff for the 2019, 2020 and 2021 and approved by DDAP staff; however, the facility remains out of compliance.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All relevant staff will review the DDAP 704.11 (c )(1) regulation by November 16, 2022. The new hire orientation process will be amended to include HIV/AIDS and TB/STD training. The training coordinator will be responsible for coordinating the new hire orientation training period and the communicable disease training. The training will be completed within the first 3 days of hire before the new employee will report to their job duties. The training coordinator is responsible for communicating the completion of these trainings to the responsible clinical manager and director after each new hire class.
This new process will be implemented by November 21, 2022. |