INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7 - 16, 2008 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 15, 2008.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a personnel and training record review, the facility failed to provide a training plan for 2008 in employee record #1.
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Plan of Correction
The President/CEO will complete an annual training plan for 2008 by February 25.
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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 training record review and a review of the facility summary report completed by the facility, the facility failed to provide the required HIV/AIDS and TB/STD training for staff. Refer to employee records # 8, 9, 10, 11, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 37, 38, 39, 40 and 41.
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Plan of Correction
HIV/AIDS and TB/STD trainings are being scheduled for all employees in question. Training will be completed by 7/18/2008. Supervisors, clinical managers and the Human Resources office will monitor for compliance |
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 a training record review, the facility failed to provide the documentation of the required hours for the 2007 training year. Refer to employee record # 12 and 16.
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Plan of Correction
Employee #12 has been scheduled for additional training and will be in compliance by 4/30/08. Employee #16 is attending a Master's program and has provided documentation of the required hours. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a client record review on 1-14-08 and 1-15-08, the facility failed to provide treatment plans in three of three client records. Refer to client records # 12, 13, and 14.
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Plan of Correction
Due to an resignation without notice, treatment plans were not present in three records. A full-time Counselor has been hired, trained and is providing treatment and completing all required documentation. The clinical supervisor is auditing charts for compliance. |
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 a client record review on 1-14-08, the facility failed to provide an informed consent to release information prior to the disclosure of information to a Probation Department. Refer to client record # 17.
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Plan of Correction
Counselor documented a disclosure without consent that was made in error in the patient record. Subsequently, a consent was procured and the patient and PO were advised of the mistake. The clinical supervisor and Director met with the counselor and training was provided. Patient records will be monitored by the clinical manager for compliance. |
709.63(a)(7) LICENSURE Discharge summary
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:
(7) Discharge summary.
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Observations
Based on a client record review on 1-14-08, the facility failed to provide discharge summaries within the seven day time frame. Two of three client records did not document discharge summaries within seven days of the discharge date and one was incomplete. The discharge summary in client record # 1 did not include the reasons for treatment, services offered or the client's response to treatment. Discharge summaries in client records # 2 and 3 were more than seven days late.
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Plan of Correction
Clinical staff attended a mandatory treatment documentation training on 1/30/08. The clinical manager also provided individual training and supervision regarding this standard with the out-patient counselor who failed to meet the standard. Client records will be monitored for compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a client record review on 1-14-08 and 1-15-08, the facility failed to provide completed treatment plan updates. Client record # 16 and 18 did not have treatment plan updates for December 2007, and client record # 17 did not have a staff signature on the treatment plan.
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Plan of Correction
Clinical staff attended a mandatory treatment documentation training on 1/30/08. The clinical manager also provided individual training and supervision regarding this standard with the out-patient counselor who failed to meet the standard. Client records will be monitored for compliance.
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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 a client record review on 1-14-08 and 1-15-08, the facility failed to provide an aftercare plan in one of one client record where required. Refer to client record # 19.
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Plan of Correction
Clinical staff attended a mandatory treatment documentation training on 1/30/08. The clinical manager also provided individual training and supervision regarding this standard with the out-patient counselor who failed to meet the standard. Client records will be monitored for compliance.
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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a facility tour on 1-15-08, the facility had 112 beds in the Inpatient non-hospital/ residential treatment and rehabilitation activity. This exceeds the licensed capacity of 110 beds.
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Plan of Correction
When new beds were purchased for the youth area, two of the old beds were not removed as planned. The two beds were removed on 1-15-2008. The patient rooms will be monitored for compliance with this standard as part of ongoing environmental rounds. |