INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 23-24, 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 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:
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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 TB/STD training in one support staff record.Employee #10 was hired as a maintenance tech on March 6, 2017. HIV/AIDS and TB/STD training was due to be completed by March 6, 2019. There was no documentation of HIV/AIDS and TB/STD training in employee #10's record as of October 24, 2019.These findings were reviewed with facility staff during the licensing process.
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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 trainings 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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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
The facility failed to implement procedures regarding the administration of client medications.Client #5 was admitted on April 1, 2019 and discharged on May 23, 2019. During that time, the client was prescribed several medications. According to the medication administration records for client #5, there were gaps in which the client did not receive the medication as prescribed - missing doses or entire days. Based on the medication administration record, it is unclear if the client refused medications, or if the facility staff did not offer them to the client. There was no documentation to indicate what occurred with the missing doses.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.32 (c) (1) LICENSURE
Medication control:
To be in compliance with Licensure regulation 709.32, All inpatient medications will be tracked through Secure Management electronic records unit.
All client medications will be input into Secure Manage by monitoring staff. The staff will utilize this system when observing clients taking prescribed medications.
On the Secure Manage System the date and time a medication was taken is documented. On this system there is a status tab that allows to indicate "accepted," "refused," "amended," or "missed." There is also a section for an observation note to document more information on status if needed and the client signs off electronically after taking medications.
Administrative Assistant will develop ongoing excel spreadsheet of all active clients their medications, and provide daily dosing times for each medication. Third Shift Monitoring staff will utilize Secure Manage and the spreadsheet to audit medication adherence. These results will be reported and overseen by the Assistant and Program Director.
For Clients who refuse or miss their any medication they will be counseled by therapy staff. Any clients who are not incompliance with adherence to medication regime for any reason will be automatically added to the doctor`s list for discussion of proper adherence, discontinuation, or possible alternative medications. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to document unusual incidents that required the presence of ambulance personnel and police.The facility's unusual incident reports were requested on October 23, 2019. It was reported by facility staff that the ambulance and police had been present at the facility during the last licensing year; however, there was no documentation of these events.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.34(c) (4)LICENSURE Reporting of Unusual Incidents:
To ensure that Gateway Erie reports all unusual incidents requiring the presence of police, fire or ambulance personnel to the Department within 3 business days, The on-call supervisor will ensure that a unusual incident report is flied on the Electronic Reporting System (ERS)https://www.ddap.pa.gov/Licensing/Pages/Unusual-Incident-Reporting.aspx
within 3 business days.
The on-call supervisor completing the ERS will print copy of the report and maintain file on site of all incidences
Persons Responsible: On-call supervisors are either the Program Director or Assistant Director |