INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on October 7-9, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gateway Rehabilitation Center was found to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 eight of twenty-seven personnel records.
Twenty-seven personnel records were reviewed during an administrative review on October 1-4, 2019. The facility failed to provide documentation of the required HIV/AIDS and/or TB/STD training in personnel records # 20, 21, 22, 23, 24, 25, 26 and 27 .
Employee #20 was hired as a counselor assistant on August 20, 2018. HIV/AIDS and TB/STD training were due to be completed by August 20, 2019. As of the date of the inspection, employee #20 had not completed HIV/AIDS training.
Employee #21 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 #21 had not completed TB/STD training.
Employee #22 is a non-clinical support staff and was hired on June 19, 2017. HIV/AIDS and TB/STD training were due to be completed by June 19, 2017. As of the date of the inspection, employee #22 had not completed TB/STD training.
Employee #23 is a non-clinical support staff and was hired on June 19, 2017. HIV/AIDS and TB/STD training were due to be completed by June 19, 2017. As of the date of the inspection, employee #23 had not completed TB/STD and HIV/AIDS training.
Employee #24 is a non-clinical support staff and was hired on September 11, 2017. HIV/AIDS and TB/STD training were due to be completed by September 11, 2019. As of the date of the inspection, employee #24 had not completed TB/STD and HIV/AIDS training.
Employee #25 is a non-clinical support staff and was hired on April 4, 2016. HIV/AIDS and TB/STD training were due to be completed by April 4, 2018. As of the date of the inspection, employee #25 had not completed TB/STD and HIV/AIDS training.
Employee #26 is a non-clinical support staff and was hired on August 7, 2017. HIV/AIDS and TB/STD training were due to be completed by August 7, 2019. As of the date of the inspection, employee #26 had not completed TB/STD and HIV/AIDS training.
Employee #27 is a non-clinical support staff and was hired on September 11, 2017. HIV/AIDS and TB/STD training were due to be completed by September 11, 2019. As of the date of the inspection, employee #27 had not completed TB/STD and HIV/AIDS training.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the 2018 and 2016 licensing inspections.
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Plan of Correction
704.11(c) (1) LICENSURE
Mandatory Communicable Disease Training:
To ensure staff at Gateway Rehab receives the training for Communicable Disease that is required within 365 days of hire for all employees, Gateway Rehab designate trainer(s) who will use the DDAP approved curriculum for TB/STD and HIV/Aids (Licensing Alert 6.1997). Gateway Rehab will offer this training one time every two months starting January 1, 2020 to ensure all staff have an opportunity for training.
Additionally, Gateway Rehab Executive Management has approved to withhold pay increases of staff who fail to comply with the mandatory training requirements.
Employees who have not complied with the mandatory training requirements are registered to complete the required training by 1/1/2020.
The applicable policy and procedure will be reviewed and revised to reflect these changes.
Person(s) responsible: Program Directors, Vice President of Human Resources
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to maintain a fire drill record which included the exit route used.
The fire drill logs for the period of October 2018 - September 2019 was reviewed on October 7, 2019. None of the fire drill logs included documentation of the exit routes used during each drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
§ 705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
To ensure patients and staff use all emergency exits, practice drills will be held monthly that expand to use of all existing emergency exits. This will provide additional safety and ease of egress for the entire building.
The D3 Life Safety/Emergency Management Form Monthly Fire/Evacuation Drill Report will be modified to include a prompt to ensure the use of alternating exits. All locations will name all exits, to ensure we are using consistent language in the monthly fire drill documentation.
All applicable staff will be educated on the modified emergency management requirements and name of the applicable exits for each location.
Emergency Evaluation Plans will be updates to include names of the exits of each location.
On-going monthly monitoring of the documentation will occur by each program Director.
Person(s) responsible: Program Directors and Vice President, Operations
Time frame for Completion: 12/1/2019
Ramsey Hall Emergency Exits = 7
Abe's Place Emergency Exits = 12
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility ' s physician failed to document a face to face determination of whether an individual was currently physiologically dependent upon a narcotic drug with at least a one-year history of dependence prior to the administration of buprenorphine in one of eight patient records reviewed on October 7 - 9, 2019.
Patient # 9 was admitted August 1, 2019. The patient was administered buprenorphine on August 2, 2019. The face to face examination was not documented until August 3, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway Rehab will modify the Loss of Connectivity process to include a physician checklist to ensure the documentation captures the required elements: Physician face-to-face to determine whether an individual is currently physiologically dependent on a narcotic drug and has been physiologically dependent for more than 1 year.
The Director of Health Information Management will audit patient records to ensure physician compliance and will report audit findings to the Vice President of Operations and the Director of Nursing.
Education will be provided to the Medical Team via the director of Nursing and the Director of Health Information Management.
Target date for completion: 12/1/2019
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to document a voluntary, written, informed consent prior to the administration of buprenorphine in three of eight patient records reviewed on October 7 - 9, 2019.
Patient # 3 was admitted May 17, 2019. The patient was administered buprenorphine on May 18, 2019. No consent was documented.
Patient # 8 was admitted August 23, 2019 and discharged October 7, 2019. The patient was administered buprenorphine on August 24, 2019. The consent was not signed until August 26, 2019.
Patient # 9 was admitted August 1, 2019. The patient was administered buprenorphine on August 2, 2019. No consent was documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway Rehab will modify the Loss of Connectivity process to include a Medical Loss of Connectivity Checklist to ensure compliance of patient informed consent prior to the administration of an agent for either maintenance or detoxification.
The Director of Nursing will educate the medical team. The Director of Health Information Management (HIM) department will do daily audits for 90 days to ensure compliance with informed consent and will report audit findings to the Director of Inpatient Services, Vice President of Operations and Director of Nursing.
Target Date for Completion: 12/1/2019
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