INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 17-18, 2018 of Gateway Mt Pleasant 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 Mt Pleasant 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(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
The facility failed to document at least 4 hours of tuberculosis, sexually transmitted disease training in 2 of 21 personnel records reviewed.
Employee # 6, a counselor, was hired on October 10, 2016 and was due to have the communicable disease trainings no later than October 10, 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 # 7, a counselor, was hired on October 3, 2016 and was due to have the communicable disease trainings no later than October 3, 2017. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
|
Plan of Correction
Employee #6 and #7 is missing the required HIV/AIDS and TB/STD trainings within one year of hire. Employee #6 will sign up for and complete the next feasible HIV/AIDS and TB/STD trainings. Employee #7 has resigned.
The Program Director of the Westmoreland site 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 deficiency will be corrected by March 31, 2019.
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
The facility failed to document the completion of 12 annual training hours in employee # 2's personnel record and 25 annual training hours in employee #'s 6 and 7.
Employee # 2 was hired on March 24, 2004 and promoted to current position on February 26, 2017. There was only 4 hours documented in the personnel record for the training year reviewed.
Employee # 6 was hired on October 16, 2016 and was still employed in that position as of the date of the inspection. There was only 16 hours documented in the personnel record for the training year reviewed.
Employee # 7 was hired on October 3, 2016 and and was still employed in that position as of the date of the inspection. There was only 16 hours documented in the personnel record for the training year reviewed.
|
Plan of Correction
Employee #2 is no longer the acting director and the current director and Human Resources have a formulated plan to ensure that the current director's training hours are met for 2019.
Employee #6 will ensure that she has received all 25 hours of training for 2019. The Program Director will meet with her/him to review the planned training hours for the year to ensure that he/she is meeting the regulation. Employee #7 has resigned.
The Program Director will monitor to ensure that all training hours are complete and documentation of the completion will be available.
This deficiency will be corrected immediately.
|
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
During a physical plant inspection, it was observed that the facility failed to ensure the water temperatures not exceed 120 degrees in the main lobby staff bathroom and client rooms # 101 and 102. The staff bathroom water temperature was 135 degrees, client room # 101 was 140 degrees and client room # 102 was 130 degrees.
|
Plan of Correction
The water temperature in the staff bathroom and rooms #101 and #102 exceeded 120F.
The water temperature is Excela Frick Hospital's responsibility. A process will be developed for the water temperature to be monitored by staff bi-weekly. Staff will inform the Program Director when the water temperature exceeds 120F. The Program Director contact Excela Frick Hospital and request that the temperature be lowered to not exceed 120F.
This deficiency will be corrected immediately
|
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
The facility failed to ensure a fire drill was conducted at least once a month and that every six months one drill would be conducted during sleeping hours.
There was no documentation of a fire drill during the month of October 2017.
There was documentation of only one sleeping hours fire drill in 2017.
|
Plan of Correction
Fire drill was not performed during October 2017 and only one sleeping hour's fire drill in 2017.
Program Director will develop a reminder mechanism to ensure unannounced fire drills will be performed monthly and during sleeping hours.
The Program Director will monitor monthly completion of fire drills.
This deficiency will be corrected immediately.
|
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.
|
Observations
The facility failed to document an annual written individual staff performance evaluation for employee # 1.
Employee # 1 was hired on May 2, 2000 and prompted to the current position on February 12, 2017. There was no documentation of an annual evaluation in the personnel record.
|
Plan of Correction
All Vice Presidents will receive a yearly Performance Evaluation in October.
The VP of human resources will monitor completion of yearly Performance Evaluations.
This deficiency was corrected as of October 31, 2018.
|
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
|
Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 1's record.
Client # 1 was admitted on October 11, 2018 and was still an active client at the time of the inspection. A consent to release form was signed and dated on October 12, 2018 to a police station that allowed information to explain and/or answer questions pertaining to the intake process and/or Gateway Rehab services, to gather information to assist in evaluation or social/psychological status, including chemical use, invite family members or concerned persons to participate in the family wellness group, notify family members or concerned persons listed of progress during treatment and of discharge.
|
Plan of Correction
The Director of Health Information revoked invalid Release of Information that was/were not in compliance with PA Code 255.5.
Westmoreland ? 1581839
The Director of Health Information Management will re-educate the applicable Administrative Assistant staff on confidentiality issues namely PA Code 255.5 (b) and proper completion of Release of Information Forms.
The Director of Health Information will review and monitor compliance on a weekly basis for one month, and then monthly for six month, a total of seven months. An in-service training that addresses proper completion of Release of Information Forms will be scheduled within four months.
Audit findings will be reviewed with the Program Directors as well as the Risk Management Committee.
|
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
The facility failed to document type and frequency in 5 of 7 client records reviewed.
Client # 8 was admitted on September 30, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on October 6, 2018 that did not include type and frequency for group sessions.
Client # 9 was admitted on October 13, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on October 14, 2018 that did not include type and frequency for group sessions.
Client # 10 was admitted on October 15, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on October 15, 2018 that did not include type and frequency for individual or group sessions.
Client # 11 was admitted on October 8, 2018 and was still an active client at the time of the inspection. A comprehensive treatment plan was developed with the client on October 14, 2018 that did not include type and frequency for group sessions.
Client # 14 was admitted on April 25, 2018 and was discharged on May 22, 2018. A comprehensive treatment plan was developed with the client on April 26, 2018 that did not include type and frequency for group sessions.
|
Plan of Correction
Treatment plan did not include type and frequency of treatment and rehabilitation services for client #8, #9, #10, #11 and #14.
Therapist will be reminded to include type and frequency of individual and group sessions in individual treatment and rehabilitation plans.
The Program Director will review individual and rehabilitation treatment plans and to ensure that type and frequency is documented.
This deficiency will be corrected immediately.
|
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
The facility failed to document services being provided according to the individual treatment plan in 3 of 7 records reviewed.
Client # 8 was admitted on September 30, 2018 and was still an active client at the time of the inspection. The individual treatment plan indicated 1 individual session weekly. The chart's record of service and progress notes indicated that the client had received no individual sessions the week of October 7-13, 2018.
Client # 13 was admitted on June 18, 2018 and was discharged on July 13, 2018. The individual treatment plan indicated 1 individual session weekly. The chart's record of service and progress notes indicated that the client had received no individual sessions the week of June 24-30, 2018.
Client # 14 was admitted on April 25, 2018 and was discharged on May 22, 2018. The individual treatment plan indicated 1 individual session weekly. The chart's record of service and progress notes indicated that the client had received no individual sessions the week of May 13-19, 2018.
|
Plan of Correction
Counseling services were not provided according to individual treatment and rehabilitation plan. Treatment plan indicated 1 individual session weekly, client #8 did not receive an individual session October 7-13, 2018, client #13 did not receive an individual session June 24-30, 2018, and client #14 did not have an individual session for May 13-19, 2018.
A process will be developed to ensure that counseling services are provided and documented according to individual and rehabilitation treatment plans. An audit will be conducted monthly to ensure that individual sessions are being provided according to individual treatment and rehabilitation plans. If an individual session does not take place the reason will be documented.
This deficiency will be corrected immediately.
|