INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5-10, 2009 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 and a plan of correction is due on February 5, 2009.
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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 the review of personnel records, the facility failed to document that staff received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the required time frames in eight of sixteen personnel records.
Findings:
Twenty personnel records were reviewed on December 18 and 19, 2008. Sixteen personnel records were required to have 6 hours of HIV/AIDS and 4 hours of STD/TB training. The facility did not document staff persons had received the required training in personnel records # 4, 5, 13, 16, 17, 18, 19 and 20.
In records # 4, 16 and 19, the facility did not document that the staff had received the required HIV/AIDS and STD/TB training.
In record # 4, the trainings were to be completed by 6/26/2007.
In record # 16, the trainings were to be completed by 5/11/06.
In record # 19, the trainings were to be completed by 10/23/07.
In records # 5, 13 and 20, the facility did not document that the staff had received the required STD/TB training.
In record # 5, the training was to be completed by 9/18/2007.
In record # 13, the training was to be completed by 9/1/06.
In record # 20, the training was to be completed by 3/13/2007.
In records # 17 and 18, the facility did not document that the staff had received the required HIV/AIDS training.
In record # 17, the training was to be completed by 12/12/2006.
In record # 18, the training was to be completed by 9/6/2006.
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Plan of Correction
Staff who are out of compliance will attend one of two scheduled HIV/AIDS trainings on 2/27/09 or 3/13/09.
Staff who are out of compliance will attend TB/STD training no later than 6/30/2009. |
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.
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Observations
Based on the review of personnel records, the facility failed to document that each counselor complete at least 25 clock hours of training annually in two of three records.
Findings:
Twenty personnel records were reviewed on December 18 and 19, 2008. Four personnel records were reviewed as counselors. Three were required to have 25 clock hours of annual training. The facility did not document that staff had received the required training hours in records # 13 and 14.
There were zero documented training hours in record # 13.
There were seven documented training hours in record # 14.
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Plan of Correction
The staff person with zero training hours has been on an emergency medical leave and is not likely to return. If he does we will schedule him immediately for training unless he can produce documentation that he has already received 25 hours of training in 2008. The other staffperson is scheduled for training and will be in compliance no later than 2/28/09. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill log, it was determined that the facility failed to conduct a fire drill during sleeping hours at least every six months.
The findings were:
A review of the fire drill log was conducted on January 9, 2009. The documented fire drill during sleeping hours occurred on July 25, 2008. The fire drill log indicated that no fire drill during sleeping hours had taken place in the previous six months. Fire drills documented from January to June of 2008 had all taken place during awake hours.
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Plan of Correction
Fire drills during sleeping hours are conducted quarterly. The master grid for Gateway's firedrill log did not indicate that the firedrills conducted on April 29, 2008 and October 28, 2008 were done during sleeping hours. However the Fire Drill Reports did. The Director of Medical Records will retrain medical records staff to accurately document all firedrills on the master grid. This will be completed by 3/1/2009. The Medical Records Director and Senior Director will audit for compliance.The Senior Director and Director of Environmental Services will ensure that the drills are conducted as required. |
709.83(a)(10) LICENSURE Client records
709.83. 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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document a discharge summary in one of two client records.
Findings:
Twenty one clients records were reviewed on January 5-9, 2009. Six client records were reviewed as inpatient records. Two client records were required to have discharge summaries. The facility did not document that a discharge summary had been completed in client record # 11.
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Plan of Correction
The Clinical Manager will discuss this error during supervision with the counselor no later than 2/15/2009. The counselor will be retrained on discharge requirements and documentation. The Clinical Manager will audit 100% of the counselor's patient records for compliance for 6(six) months. |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document an attempt to follow up with the client in one of three client records.
Findings:
Twenty one clients records were reviewed on January 5-9, 2009. Six were reviewed as inpatient records. Three were required to have documentation of attempts to follow up on the client. The facility did not document follow up attempts as required in client record # 12.
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Plan of Correction
The Director of Reasearch and Evaluation, The Executive Vice-President of Treatment and the Directors will develop a new policy and procedure to foolproof the acquisition and routing of Consents for Follow-up. Copies of signed and declined consents will be regularly forwarded to the Research Department for follow-up. Implementation will occur no later that June 1, 2009. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document a complete client record which includes case consultation notes, in two of five client records.
Findings:
Twenty one client records were reviewed on January 5-10, 2009. Six client records were reviewed as inpatient records. Five client records were required to have case consultation notes. The facility did not document case consultation notes in client records # 7 and 8.
In client records # 7 and 8, the facility did not document that a case consultation had been conducted at least once, where the client's treatment had been less than 90 days.
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Plan of Correction
All counseling staff at the Aliquippa site will receive training to review documentation of case consultation as well as other required documentation during early February, 2009. All Clinical Managers will complete this training no later than February 20, 2009. Clinical Managers will regularly audit patient records for compliance. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document an aftercare plan in one of two client records.
Findings:
Twenty one client records were reviewed on January 5-9, 2009. Six client records were reviewed as outpatient records. Two client records were required to have an aftercare plan. The facility did not document that an aftercare plan had been completed in client record # 16.
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Plan of Correction
The Clinical Manager will discuss this error during supervision with the counselor no later than 2/15/2009. The counselor will be retrained on discharge requirements and documentation. The Clinical Manager will audit 100% of the counselor's records for compliance for 6 (six) months. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
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Observations
Based on the review of client records, the facility failed to document a discharge summary in one of three client records.
Findings:
Twenty one client records were reviewed on January 5-9, 2009. Six client records were reviewed as outpatient records. Three client records were required to have a discharge summary. The facility did not document that a discharge summary had been completed in client record # 17.
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Plan of Correction
The Clinical Manager will discuss this error during supervision with the counselor no later than 2/15/2009. The counselor will be retrained on discharge requirements and documentation. The Clinical Manager will audit 100% of the counselor's records for compliance for 6 (six) months. |
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow- up in one of three client records.
Findings:
Twenty one client records were reviewed on January 5-9, 2009. Six client records were reviewed as outpatient records. Three client records were required to have documentation of attempts to follow-up on the client. The facility did not document follow up attempts as required in client record # 17.
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Plan of Correction
The Director of Research and Evaluation, The Executive Vice-President of Treatment and the Directors will develop a new policy and procedure to foolproof the acquisition and routing of Consents for Follow-up. Copies of signed and declined consents will be regularly forwarded to the Research Department for follow-up. Implementation will occur no later that June 1, 2009. |