INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6-8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. 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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704.11(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, the facility failed to provide documentation of HIV/AIDS and/or TB/STD training in thirteen of twenty-three personnel records.
The findings include:
Twenty-five personnel records were reviewed on November 4, 2013. Twenty-three personnel records were required to have documentation of HIV/AIDS and/or TB/STD training. The facility failed to provide documentation of the required HIV/AIDS and/or TB/STD training in personnel records # 3, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25.
Employee #3 is a counselor and was hired (as a counselor assistant) on July 9, 2012. HIV/AIDS and TB/STD training were due to be completed by July 9, 2013. As of the date of the inspection, employee #3 had not completed HIV/AIDS training.
Employee #14 is a non-clinical support staff and was hired on December 6, 2010. HIV/AIDS and TB/STD training were due to be completed by December 6, 2012. As of the date of the inspection, employee #14 had not completed TB/STD training.
Employee #15 is a non-clinical support staff and was hired on January 7, 2000. HIV/AIDS and TB/STD training were due to be completed by January 7, 2002. As of the date of the inspection, employee #15 had not completed TB/STD training.
Employee #16 is a non-clinical support staff and was hired on March 7, 2011. HIV/AIDS and TB/STD training were due to be completed by March 7, 2013. As of the date of the inspection, employee #16 had not completed TB/STD training.
Employee #17 is a non-clinical support staff and was hired on July 6, 1998. HIV/AIDS and TB/STD training were due to be completed by July 6, 2000. As of the date of the inspection, employee #17 had not completed TB/STD training.
Employee #18 is a non-clinical support staff and was hired on June 7, 2000. HIV/AIDS and TB/STD training were due to be completed by June 7, 2002. As of the date of the inspection, employee #18 had not completed TB/STD training.
Employee # 19 is a non-clinical support staff and was hired on January 31, 2011. HIV/AIDS and TB/STD training were due to be completed by January 31, 2013. As of the date of the inspection, employee #19 had not completed the HIV/AIDS and TB/STD training.
Employee # 20 is a non-clinical support staff and was hired on August 13, 2007. HIV/AIDS and TB/STD training were due to be completed by August 13, 2009. As of the date of the inspection, employee # 20 had not completed TB/STD training.
Employee #21 is a non-clinical support staff and was hired on February 28, 2011. HIV/AIDS and TB/STD training were due to be completed by February 28, 2013. As of the date of the inspection, employee #21 had not completed the HIV/AIDS and TB/STD training.
Employee #22 is a non-clinical support staff and was hired on April 13, 2009. HIV/AIDS and TB/STD training were due to be completed by April 13, 2011. As of the date of the inspection, employee #22 had not completed the HIV/AIDS training.
Employee #23 is a non-clinical support staff and was hired on November 12, 2001. HIV/AIDS and TB/STD training were due to be completed by November 12, 2003. As of the date of the inspection, employee #23 had not completed the HIV/AIDS and TB/STD training.
Employee #24 is a non-clinical support staff and was hired on August 16, 2010. HIV/AIDS and TB/STD training were due to be completed by August 16, 2012. As of the date of the inspection, employee #24 had not completed the HIV/AIDS and TB/STD training.
Employee #25 is a non-clinical support staff and was hired on October 15, 2007. HIV/AIDS and TB/STD training were due to be completed by October 15, 2009. As of the date of the inspection, employee #25 had not completed TB/STD training.
The aforementioned information was confirmed by the HR director and the facility director.
This is a repeat citation from the 2007, 2008, 2009, 2010 and 2012 licensing inspections.
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Plan of Correction
The 13 staff members that have not completed the Mandatory HIV/AIDS and/or TB/STD Trainings will be scheduled to attend immediately and will be in compliance by 5/31/14 (based on training availability). The Department Directors will be responsible to make sure this task is completed. Department Directors, along with Human Resources, will monitor these trainings for all staff on an on-going basis throughout the year. |
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 the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
The physical plant inspection was conducted on November 8, 2013 at approximately 10:30 AM. During the inspection, the licensing specialist observed a counseling session occurring in the IRU 2 in which the window blinds were not closed. The licensing specialist could clearly see both the counselor and client in the counseling office.
The aforementioned information was confirmed by the clinical supervisor.
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Plan of Correction
The Clinical Manager issued written notification on 11/25/13 to IRU2 clinical staff reviewing privacy requirements for counseling sessions. The Clinical Manager will monitor this issue on an on-going basis. The Department Director will ensure this process is taking place on an on-going basis. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release client information form was obtained in one of twenty client records.
The findings included:
Twenty-three client records were reviewed November 6 through November 8, 2013. Twenty records were reviewed regarding consent forms for the release of client information. The facility failed to ensure that an informed and voluntary consent to release client information form was obtained in client record # 3.
Client #3 was admitted on July 9, 2013 and discharged on July 12, 2013. Information contained in the client record was released to the client's funding source on July 10, 2013. The facility failed to obtain an informed and voluntary consent to release client information form for the funding source documented in record #3.
The aforementioned information was confirmed by the facility director on November 8, 2013.
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Plan of Correction
A review training with all Admissions staff will be conducted by 1/1/14 regarding informed and voluntary consent. Each consent and its accuracy and completeness will be monitored on an on-going basis by the Admissions Manager. The Admissions Manager will follow up with any specific staff members provide individual direction when needed. The Admissions Manager will ensure this process is taking place on an on-going basis. |
709.63(a) LICENSURE Client record
709.63. 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record that included a record of service, consent form and/or follow-up information in six of twelve client records.
The findings include:
Twelve detox client records were reviewed on November 6-8, 2013. The facility failed to document a complete client record that included a record of service, consent form and/or follow-up information in client records # 1, 2, 4, 5, 6 and 7.
Client #1 was admitted to detox on May 19, 2013 and discharged on May 21, 2013. The facility failed to obtain a follow-up consent form for client #1.
Client #2 was admitted to detox on March 16, 2013 and discharged on March 23, 2013. Client #2 participated in group therapy on March 20, 21 and 22. The facility failed to document the group sessions on the record of service.
Client #4 was admitted to detox on March 23, 2013 and discharged on March 27, 2013. Client #4 participated in group therapy on March 25 and 26. The facility failed to document the group sessions on the record of service. Additionally, follow-up was due to be completed by September 27, 2013. The facility failed to document that follow-up was completed as of the date of inspection.
Client #5 was admitted to detox on September 14, 2013 and discharged on September 18, 2013. Client #5 participated in group therapy on September 18, 2013. The facility failed to document the group session on the record of service.
Client #6 was admitted to detox on April 1, 2013 and discharged on April 4, 2013. Follow-up was due to be completed by October 4, 2013. The facility failed to document that follow-up was completed as of the date of inspection.
Client #7 was admitted to detox on April 20, 2013 and discharged on April 24, 2013. Follow-up was due to be completed by October 24, 2013. The facility failed to document that follow-up was completed as of the date of inspection.
The aforementioned information was confirmed by the facility director on November 8, 2013.
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Plan of Correction
A training to review the processes regarding Record of Service, Follow-up Consents and Follow-up Calls with all pertinent Detox staff has been completed by the Detox Clinical Manager. Each of these processes will be monitored on an on-going basis by the Detox Clinical Manager with formal reviews of each medical record after discharge. The Detox Clinical Manager will follow up with specific staff members and provide individual direction when needed. The Director of Detox & Nursing Services will ensure this process is taking place on an on-going basis. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document an update of the client's treatment and rehabilitation plans in two of five client records.
The findings include:
Nine inpatient client records were reviewed on November 6-8, 2013. Five of the nine client records reviewed required a treatment plan update. The facility failed to document an update of the treatment and rehabilitation plans in client records #15 and 21.
Client #15 was admitted on April 12, 2013 and discharged on April 23, 2013. The record included documentation identified as a treatment plan update that was completed on April 18, 2013. The treatment plan update did not include an update of the client's treatment plan goals.
Client #21 was admitted on May 23, 2013. The record included documentation identified as treatment plan updates that were completed on July 11, August 22, September 9, October 4 and November 6, 2013. None of the treatment plan updates contained in record #21 included an update of the client's treatment plan goals.
The findings were confirmed with the facility director on November 8, 2013.
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Plan of Correction
A training to review treatment plan updates, including documentation on progress toward goals, will be conducted with Rehab clinical staff by 1/30/14 by the Clinical Managers. Clinical Managers will monitor this process on an on-going basis with formal reviews of each medical record after discharge. The Department Director will ensure this process is taking place on an on-going basis.
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