INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26-30, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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:
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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 and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #17 was hired as a shift supervisor on February 3, 2020 and was due to have the communicable disease trainings no later than February 3, 2022. The HIV/AIDS training was not completed until April 19, 2022.
Employee #18 was hired as an Inpatient Registration Coordinator on February 17, 2020 and was due to have the communicable disease trainings no later than February 17, 2022. The HIV/AIDS training was not completed until July 8, 2022.
Employee #19 was hired as a driver on March 16, 2020 and was due to have the communicable disease trainings no later than March 16, 2022. The TB/STD training was not completed until April 29, 2022
Employee #20 was hired as a shift supervisor on May 18, 2020 and was due to have the communicable disease trainings no later than May 18, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #21 was hired as a detox supervisor on June 9, 2020 and was due to have the communicable disease trainings no later than June 9, 2022. The HIV/AIDS and TB/STD training were not completed until September 17, 2022
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the October 9, 2019, August 24, 2020, and September 30, 2021 licensing inspection.
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Plan of Correction
All relevant staff will review the DDAP 704.11 (c)(1) regulation by November 7, 2022. The new hire orientation process will be amended to include HIV/AIDS and TB/STD training. The training coordinator will be responsible for coordinating the new hire orientation training period and the communicable disease training. The training will be completed within the first 3 days of hire before the new employee will report to their job duties.
The training coordinator is responsible for communicating the completion of these trainings to the responsible clinical manager and director after each new hire class.
This new process will be implemented by November 7, 2022. |
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 review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 24 clock hours of annual training required for counselors.
Employee #15 was hired as a counselor on November 30, 2015 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2021 through December 31, 2021. Employee # 15's record only documented 1.5 hours of annual training for the training year reviewed.
Employee #16 was hired as a counselor on March 13, 2006 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2021 through December 31, 2021. Employee # 16's record only documented 13.25 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All relevant staff will review the DDAP 704.11 (f )(2) regulation by (DATE). They will sign off on their understanding of the requirement for yearly 25 clock hour training. The training coordinator will audit training hours for all staff monthly and send an updated training chart to the clinical managers and directors of each location.
During supervision, the clinical manager and/or director will review the monthly clock hours and document on the supervision form that the training hours were discussed.
Once a month, there will be a minimum of 2 hour all staff training at each location during a staff meeting to add to staff training hours for the year.
The clinical managers and directors will be educated by November 15, 2022 on the new training audit process and will be implemented by December 1, 2022. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling room.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway Rehabilitation Center will request the waiver to allow cameras in the group rooms by December 1, 2022.
Until we request and obtain a decision, the camera will be turned off.
If the waiver is denied by DDAP, Gateway Rehabilitation Center will remove the cameras in the group rooms within 5 business days of receiving the denial. |
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
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure two employees received the required training in the use of the fire extinguishers upon employment.
Employee #10 was hired on April 26, 2022 for the position of counselor and was still employed at the time of the inspection. He did not have the training until May 13, 2022.
Employee #11 was hired on February 14, 2022 for the position of counselor and was still employed at the time of the inspection. She did not have the training until May 13, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All relevant staff will review the DDAP 705.10 (c ) (4) regulation by November 7, 2022. The Training Coordinator will be responsible for ensuring all staff receive the required fire extinguisher training upon hire (New Hire Orientation). The Training Coordinator will review all staff training records (including those records from New Hire Orientation) during the Orientation Process to ensure training is complete.
This new process will begin November 7, 2022. |
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
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure two employees received the required training to perform assigned tasks during emergencies.
Employee #10 was hired on April 26, 2022 for the position of counselor and was still employed at the time of the inspection. He did not have the training until May 13, 2022.
Employee #11 was hired on February 14, 2022 for the position of counselor and was still employed at the time of the inspection. She did not have the training until May 13, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All relevant staff will review the DDAP 705.10 (d) (3) regulation by November 7, 2022. The Training Coordinator will be responsible for ensuring all staff receive the required emergency procedure training upon hire (New Hire Orientation). The Training Coordinator will review all staff training records (including those records from New Hire Orientation) during the Orientation Process to ensure training is complete.
This new process will be implemented by December 1, 2022 |
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 October 21, 2021 through August 13, 2022 fire drill logs during the inspection, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A sleeping drill was completed on December 18, 2021 and not again until August 13, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Staff conducted fire drill during sleeping hours, on October 10, 2022. The drill was recorded in Gateway's D3 fire drill log.
The facility manager & director will maintain a schedule of all required fire drills. All drills were scheduled on the relevant facility staff's outlook calendar to include an overnight drill every 3 months.
Upon completion of overnight drills staff record results of drill in Gateway's D3 system/fire drill log and submit an email to manager/director confirming drill was completed.
GRC Risk Management Committee will monitor all fire drills submitted on D-3 system and send monthly report to director for follow-up.
Director will review report to ensure that fire drill during sleeping hours is being completed. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of staff training records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for mandatory communicable disease training were submitted and approved by the Department for the September 30, 2021, August 24, 2020, October 9, 2019, and September 19, 2018 annual licensing inspections. Mandatory communicable disease training was again found to be a deficiency in the September 30, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All relevant staff will review the DDAP 704.11 (c)(1) regulation by November 7, 2022. The new hire orientation process will be amended to include HIV/AIDS and TB/STD training. The training coordinator will be responsible for coordinating the new hire orientation training period and the communicable disease training. The training will be completed within the first 3 days of hire before the new employee will report to their job duties.
The training coordinator is responsible for communicating the completion of these trainings to the responsible clinical manager and director after each new hire class.
This new process will be implemented by November 7, 2022. |