INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19-20, 2018 of Gateway Rehabilitation Center by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gateway Rehabilitation Center 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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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
The facility failed to document counselor assistant supervision by a full - time clinical supervisor or counselor in 4 of 5 personnel records reviewed.
Employee # 6 was hired on March 12, 2018 and was still employed at the time of the inspection. The supervision notes did not have documentation of clinical supervisor or counselor providing the supervision.
Employee # 9 was hired on January 4, 2018 and was still employed at the time of the inspection. The supervision notes did not have documentation of clinical supervisor or counselor providing the supervision.
Employee # 11 was hired on June 18, 2018 and was still employed at the time of the inspection. The supervision notes did not have documentation of clinical supervisor or counselor providing the supervision.
Employee # 15 was hired on January 2, 2018 and was still employed at the time of the inspection. The supervision notes did not have documentation of clinical supervisor or counselor providing the supervision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Documentation will include staff full name, direct supervisor full name , date, intervention (individual or group) and signature of both staff members.
Director and clinical manager of that staff person will monitor on a monthly basis.
Form will be created and implemented by 11/30/2018
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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
The facility failed to document a semi-annual review for 2 of 5 personnel records reviewed.
Employee # 9 was hired on January 4, 2018 and was still employed at the time of the inspection. A semi-annual review was due on July 4, 2018.
Employee # 10 was hired on January 15, 2018 and was still employed at the time of the inspection. A semi-annual review was due on July 15, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
VP and Director of Human Resources will send correspondence to supervisor to remind them of upcoming Performance Reviews-1 month in advance. This correspondence will include the direct supervisor and the supervisors Director.
The Director of the program will review all PE's due that month with each manager in supervision.
This process will be implemented on or by 11/30/18. |
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
The facility failed to document an individual training plan for 3 of 21 personnel records reviewed.
Employee # 9 was hired on January 4, 2018 and was still employed at the time of the inspection. There was no documentation of an individual training plan for 2018 in the personnel record.
Employee # 19 was hired on August 20, 2018 and was still employed at the time of the inspection. There was no documentation of an individual training plan for 2018 in the personnel record.
Employee # 20 was hired on August 20, 2018 and was still employed at the time of the inspection. There was no documentation of an individual training plan for 2018 in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will monitor new hire orientation list and follow up with in 7 days to verify HR has received proper paperwork.
Director of the facility and Human Resources will implement this process on or before 10/19/18.
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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
The facility failed to ensure that employee's # 24, 25, 26, 27, 28, 29, 30, 31, 32, and 33 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #24 was hired as a direct support professional on August 11, 2014 and was due to have the communicable disease trainings no later than August 11, 2016. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #25 was hired as a direct support professional on May 29, 2012 and was due to have the communicable disease trainings no later than May 29, 2014. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #26 was hired as a direct support professional on July 8, 2016 and was due to have the communicable disease trainings no later than July 8, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #27 was hired as a direct support professional on January 12, 2015 and was due to have the communicable disease trainings no later than January 12, 2017. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #28 was hired as a direct support professional on March 28, 2016 and was due to have the communicable disease trainings no later than March 28, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #29 was hired as a direct support professional on September 8, 2014 and was due to have the communicable disease trainings no later than September 8, 2016. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #30 was hired as a direct support professional on April 4, 2016 and was due to have the communicable disease trainings no later than April 4, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #31 was hired as a direct support professional on August 17, 2015 and was due to have the communicable disease trainings no later than August 17, 2017. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #32 was hired as a direct support professional on July 9, 2012 and was due to have the communicable disease trainings no later than July 9, 2014. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #33 was hired as a direct support professional on July 5, 2016 and was due to have the communicable disease trainings no later than July 5, 2018. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
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Plan of Correction
The director of inpatient services and manager of the program will monitor to ensure this training is complete.
In addition, Human Resources will send quarterly reminders to all managers reminding them to review the Human Resources training spreadsheet. This reminder will also include time parameters for DDAP required trainings.
This will be in place on or before 11/5/2018
**The staff who are listed below who have not received the training will be signed up as soon as a training becomes available.
*** An appeal for the following employees has been submitted: Employee # 17, #19, #20, and # 21. Their training was available at time of review or they have been employed less than 1 year at time of review.
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704.11(e)(2) LICENSURE Annual Trng Req-Clin Sup
704.11. Staff development program.
(e) Training requirements for clinical supervisors.
(2) Each clinical supervisor shall complete at least 12 clock hours of training annually in areas such as:
(i) Supervision and evaluation.
(ii) Counseling techniques.
(iii) Substance abuse trends and treatment methodologies in the field of addiction.
(iv) Confidentiality.
(v) Codependency/Adult Children of Alcoholics (ACOA) issues.
(vi) Ethics.
(vii) Interaction of addiction and mental illness.
(viii) Cultural awareness.
(ix) Sexual harassment.
(x) Developmental psychology.
(xi) Relapse prevention.
(xii) Disease of addiction.
(xiii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The facility failed to provide documentation of the completion of 12 clock hours of annual training required for clinical supervisors in employee #14's employee record.
Employee #14 was hired as a clinical supervisor on June 26, 2016 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2017 through December 31, 2017. Employee #14's employee record only documented 3 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of the inpatient program will monitor the training spreadsheet quarterly to ensure that all managers have 12 hours of training. This will also be reviewed in individual supervision with staff.
Human Resources will send quarterly reminds to view the training spreadsheet.
This will be corrected on or by 11/30/18. |
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
During a physical plant inspection on September 20, 2018, the facility failed to ensure that counseling sessions could not be heard outside the counseling office.
A counseling session could be heard outside of Counseling office 274.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All offices on the patient unit will be given white noise machines. The machines will be places outside of the office in the hallway and will be turned on when the staff person has a patient in the office.
This will be monitored by program manager and director of the building.
This was corrected 10/19/2018
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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
The facility failed to document an annual review for employee #1.
Employee #1 was hired on February 17, 2017 and was still employed in that position at the time of the inspection. An annual review was due no later than February 17, 2018.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Vice Presidents will receive PE October of that year. Yearly PE reviews will all be reset to October.
This will be monitored by VP, HR.
This will be corrected on or by 10/31/2018
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