INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 30, 2016 by staff from the Division of Drug and Alcohol 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:
|
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 facilty failed to document that staff persons and volunteers received 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, and all other staff shall complete the training within the first 2 years of employment.Eleven personnel records were reviewed on September 12-13, 2016. Staff records # 4, 8, 9, 10 and 11 did not include documentation of HIV/AIDS and TB/STD training within the required timeframes for their position.Employee #4 was hired as a counselor on 6/23/14. HIV/AIDS and TB/STD training was due to be completed by 6/23/15. At the time of the inspection, employee #4 had not completed HIV/AIDS and TB/STD training.Employee #8 was hired as an administrative assistant on 2/25/13. HIV/AIDS and TB/STD training was due to be completed by 2/25/15. At the time of the inspection, employee #8 had not completed HIV/AIDS and TB/STD training.Employee #9 was hired as a monitor on 12/17/12. HIV/AIDS and TB/STD training was due to be completed by 12/17/14. At the time of the inspection, employee #9 had not completed HIV/AIDS and TB/STD training.Employee #10 was hired as a monitor on 10/15/12. HIV/AIDS and TB/STD training was due to be completed by 10/15/14. At the time of the inspection, employee #10 had not completed HIV/AIDS and TB/STD training.Employee #11 was hired as a monitor on 6/9/14. HIV/AIDS and TB/STD training was due to be completed by 6/9/16. At the time of the inspection, employee #11 had not completed HIV/AIDS and TB/STD training.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the 2015 licensing inspection.
|
Plan of Correction
As a response to the citation received during our recent survey, All identified staff, #4,#8,#9,#10, as well as all other staff will have the HIV/AIDS and TB/STD training completed by a department approved curriculum. This will be completed NLT October 28th 2016 as a training is scheduled for October 27th and October 28th 2016. In the future, to ensure that all trainings are completed we will enlist the support of the Assistant Director/Clinical, Assistant Director/Security Operations, the Administrative Assistant and I to review all staff's training progress in both Annual training plans and quarterly meetings specific to staff development. This will allow Administrators and Clerical staff assigned to tracking training hours to discuss training progress and identify deficiencies with regard to meeting required training completion. A review of outstanding trainings due can then be addressed in regular supervision review sessions with individual staff to prevent any oversight that may occur and ensure that all staff remain on top of what trainings need to be completed. |
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.
|
Observations
The facility failed to document the completion of 25 clock hours of annual training required for each counselor in one of three personnel / training records.Eleven personnel / training records were reviewed on September 12-13, 2016. Four personnel records pertained to counselors. Three personnel / training records required the completion of 25 clock hours of annual training for the 2015 training year. The facility failed to document 25 clock hours of annual training in personnel / training records # 4.Employee # 4 was hired as a counselor on June 23, 2014. The facility training year is from January through December. Employee # 4 completed 19 clock hours of annual training from January through December 2015.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
To ensure that all trainings are completed, we will enlist the support of the Assistant Director/Clinical,the Administrative Assistant and I to review all staff's training progress in both Annual training plans and quarterly meetings specific to staff development. This will allow Administrators and Clerical staff assigned to tracking training hours to discuss training progress and identify deficiencies with regard to meeting required training completion. A review of outstanding trainings due can then be addressed in regular supervision sessions with individual staff to prevent any oversight that may occur and ensure that all staff complete the minimum 25 hours and remain on top of what trainings need to be completed. Any staff currently not in compliance with the 25 clock hours of annual training will be required to meet the minimum hours by 1/11/17.
|
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
|
Observations
The facility failed to document a physician signature on treatment plans and/or updates for publicly funded clients in three of three client records reviewed on September 30, 2016. Client #4 was admitted on March 21, 2016, discharged on June 22, 2016 and was publicly funded. A treatment plan update was completed on May 21, 2016. There was no physician signature on the treatment plan update.Client #6 was admitted on July 5, 2016, and was publicly funded. A treatment plan was completed on July 7, 2016 and a treatment plan update was completed on August 8, 2016. There was no physician signature on the treatment plan and the treatment plan update.Client #7 was admitted on April 11, 2016, and was publicly funded. A treatment plan was completed on April 20, 2016 and a treatment plan update was completed on June 6, 2016. There was no physician signature on the treatment plan and the treatment plan update.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Erie management team has adopted an internal policy that the Assistant Director/Clinical Manager will conduct thorough file/record reviews during the weekly clinical supervision sessions with all assigned clinicians. This file review will provide an opportunity to review all file documents for accuracy and compliance. Any documents needing the physician's signature will be placed in the medical chart review mailbox for the physician to retrieve during his weekly visit. |