INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 24, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-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
The facility failed to provide documentation that staff persons received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training based on a review of personnel/training records.
Employee # 5 is a counselor and was hired on July 9, 2012. TB/STD training was not documented.
Employee # 21 is support staff and was hired on January 4, 2018. HIV/AIDS training was not documented.
Employee # 22 is support staff and was hired on August 20, 2018. HIV/AIDS training was not documented.
Employee # 23 is support staff and was hired on August 11, 2014. TB/STD training was not documented.
Employee # 24 is support staff and was hired on June 19, 2017. HIV/AIDS training was not documented.
Employee # 25 is support staff and was hired on September 11, 2017. HIV/AIDS training was not documented.
Employee # 26 is support staff and was hired on April 14, 2016. HIV/AIDS training was not documented.
Employee # 27 is support staff and was hired on August 17, 2015. TB/STD training was not documented.
Employee # 28 is support staff and was hired on September 11, 2017. HIV/AIDS training was not documented.
Employee # 29 is support staff and was hired on August 7, 2017. HIV/AIDS training was not documented.
Employee # 30 is support staff and was hired on June 21, 2010. HIV/AIDS training was not documented.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2018 and 2019 licensing inspections.
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Plan of Correction
Gateway will be offering, per DDAP bulletin, HIV/AIDS training available quarterly to its employees. In addition Gateway will utilize the online DDAP approved offerings for HIV/AIDS and TB/STD training. The employees will be required to sign up and complete the next feasible HIV/AIDS and TB/STD training. In order to satisfy the deficiencies that we currently have, we have secured training for the employees listed below.
The following employees will be registered, once registration is open, to the appropriate contact for the virtual HIV/AIDS Part 1 and Part 2 training on November 9, 2020 and November 10, 2020:
Employee # 21 is support staff and was hired on January 4, 2018. HIV/AIDS training was not documented.
Employee # 22 is support staff and was hired on August 20, 2018. HIV/AIDS training was not documented.
Employee # 24 is support staff and was hired on June 19, 2017. HIV/AIDS training was not documented.
The following employees will be registered, once registration is open, to the appropriate contact for the virtual HIV/AIDS Part 1 and Part 2 training on December 8, 2020 and December 9, 2020:
Employee # 25 is support staff and was hired on September 11, 2017. HIV/AIDS training was not documented.
Employee # 26 is support staff and was hired on April 14, 2016. HIV/AIDS training was not documented.
Employee # 28 is support staff and was hired on September 11, 2017. HIV/AIDS training was not documented.
Employee # 30 is support staff and was hired on June 21, 2010. HIV/AIDS training was not documented.
The following employees will be registered, once registration is open, to the appropriate contact for the virtual TB/STD training on November 13, 2020:
Employee # 5 is a counselor and was hired on July 9, 2012. TB/STD training was not documented.
Employee # 23 is support staff and was hired on August 11, 2014. TB/STD training was not documented.
Employee # 27 is support staff and was hired on August 17, 2015. TB/STD training was not documented.
The following employee was terminated effective 9/23/2020, therefore this employee will not be attending HIV/AIDS training:
Employee # 29 is support staff and was hired on August 7, 2017. HIV/AIDS training was not documented.
Managers of this site will ensure staff training is completed as required by logging training into spreadsheet that is reviewed monthly during supervision with the employee(s). Director will conduct monthly random training documentation checks. The administrative assistant will track all training taken and certificates submitted and communicate with the managers and director on a monthly basis.
All managerial staff will be educated by 10/15/2020 as to the requirement of monthly review with staff during supervision. Training discussion should be logged in supervision documentation. Director will do random training checks on all new staff every 2 months. VP of Human Resources will remind all staff to check their training monthly and share applicable in house and DDAP webinar training as they are scheduled.
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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
The facility failed to document each counselor completed at least 25 clock hours of annual training for the January - December 2019 training year in employee record # 5.
Employee # 5 is a counselor and was hired July 9, 2012. Only 12 training hours were documented for the 2019 training year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee (s) will ensure that they have received all 25 hours of training in 2020. The director has met with the employee and educated her on the need to have her 25 hours completed. Further, the director has made a plan with the employee and had her register for 3 trainings that must be completed by December 9, 2020 that will satisfy her 25 hours of training needed for the 2020 licensing year.
For all employees at the site, the managers, program director, and administrative assistant will track training monthly at staff meetings and register employees for training from now until December 31, 2020 to satisfy that all employees have received the required number of training hours for the 2020 licensing year.
Site manager, program director, and Vice President of Human Resources will monitor non-compliant staff to ensure they have received required training.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document fire extinguisher training upon staff employment in employee records # 8, 14 and 19.
Employee # 8 was hired June 8, 2020. Fire extinguisher training was not documented until August 1, 2020.
Employee # 14 was hired February 17, 2020. Fire extinguisher training was not documented until August 1, 2020.
Employee # 19 was hired April 20, 2020. Fire extinguisher training was not documented until May 13, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All managerial staff will be re-educated on the need to orient staff to fire extinguisher location and use, and emergency training upon employment. HR staff will monitor completion of orientation checklist detailing completion of these two training.
Site manager, program director, and Vice President of Human Resources will monitor all new staff to ensure they have received required training.
Managerial staff will be re-educated by 10/15/20. HR staff will begin monitoring immediately.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to document that all personnel on all shifts were trained to perform assigned tasks during emergencies in employee records # 8 and 14.
Employees # 8 and 14 did not have documentation of emergency training upon employment for their assigned shift.
Employee # 8 was hired June 8, 2020. Emergency training was not documented until August 1, 2020.
Employee # 14 was hired February 17, 2020. Emergency training was not documented until August 1, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All managerial staff will be re-educated on the need to orient staff to fire extinguisher location and emergency training within seven days of hire. HR staff will monitor completion of orientation checklist detailing completion of these two training.
Site manager, program director, and Vice President of Human Resources will monitor non-compliant staff to ensure they have received required training
Managerial staff will be re-educated by 10/15/20. HR staff will begin monitoring immediately.
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