INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15, 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 Greensburg 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 document HIV/AIDS training in one of two personnel records reviewed.
Employee # 8 was hired for the position of counselor on February 6, 2017. There was no documentation of HIV/AIDS training in employee record # 8.
This is a repeat citation from the September 2018 licensing inspection.
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Plan of Correction
Citation L0067
Gateway will be offering, per DDAP bulletin, HIV/AIDS training available quarterly to its employees. This employee is no longer employed by Gateway, however making this training available quarterly will ensure all Gateway employees receive HIV/AIDS training in a timely manner in the future. Managers of each site will ensure staff training is completed as required. Director of outpatient will conduct monthly random training documentation checks. Gateway will begin offering quarterly HIV/AIDS trainings to its employees starting in January 2020. Director of outpatient services will begin random training checks in November 2019.
Date: 1/1/2020
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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.
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Observations
The facility failed to document an informed and voluntary consent from the client prior to the disclosure of information contained in the client record in one of fourteen client records reviewed on October 15, 2019.
Client # 12 was admitted April 14, 2017. Facility staff confirmed the funding entity was billed for services the week of October 7, 2019 without a consent to release information from client # 12.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Citation L0276
All outpatient administrative staff will attend a webinar given by the director of medical records regarding client confidentiality, appropriately completing consents, and instructions for obtaining appropriate consent when patient insurance changes during treatment. Consents will be obtained from all clients, including client #12, prior to the release of any information. Directors of outpatient services and medical records will ensure all outpatient administrative staff attend webinar and complete a post-webinar quiz. Completion of consents will be monitored by medical records staff. Webinar will be developed in November 2019 and all administrative staff will have completed it by January 31, 2020.
Date: 1/31/2020
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility's physician failed to document whether an individual was currently physiologically dependent upon a narcotic drug with at least a one year history of dependence prior to the administration of buprenorphine in one of four patient records reviewed on October 15, 2019.
Patient # 13 was admitted November 7, 2018 and discharged January 24, 2019. The patient was administered buprenorphine on November 8, 2018. The face to face examination was documented November 8, 2018 but not the current dependence or one year history.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Citation NM059
Citation NM059
Physician will be re-educated on the importance of completing documentation completely and accurately at all times, especially when completing an initial prescription of buprenorphine. Physician will document current dependency and one year history prior to prescribing buprenorphine. Manager of Greensburg and director of outpatient services will monitor physician documentation for completeness and accuracy. Physician will be re-educated by 11/30/19, and documentation monitoring will commence immediately.
Date: 11/30/2019
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