INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 20-21, 2009 by staff from the Division of Drug and Alcohol Program Licensure. 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 and a plan of correction is due on February 27, 2009.
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Plan of Correction
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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
Based on the review of personnel records, the facility failed to document that each counselor completed at least 25 clock hours of training annually in one of two records.
Findings:
Four personnel records were reviewed on December 18-19, 2008. Two were reviewed as counselors. Two were required to have at least 25 clock hours of training annually. There was no documentation to demonstrate that the employee had obtained 25 training hours for the 2008 training year in personnel record #3. The personnel record documented only 19 training hours.
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Plan of Correction
1) The training plan will be developed in January with the employee.
2) Specific training Objectives will be developed in reference to the previous Performance Appraisal.
3) Training compliance will be reviewed quarterly with the training officer and the Program Director
4) Deficiencies will be brought to the attention of the individual and their supervisor via E-mail memo.
5) Completed training records including certificates and staff development forms will be copied and origionals sent to Human resources |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to prohibit facility heaters that are not permanently mounted or installed within the building.
Findings:
During the physical plant inspection on January 21, 2009, a small space heater was found in the administrative office. The heater was not permanently mounted or installed.
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Plan of Correction
The nature of this old building, the harshness of the winter and the fact that we did not want to make permanant modifications to a building that we would soon be leaving caused us to use u.l. approved supplemental heaters in non- patient areas.
The heaters have been removed and disposed of by the maintenance man as of this date ( 02/02/2009 ).
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of client records, observations made by Licensing Specialists, and discussions with the facility director, the facility failed to ensure the confidentiality of client identity and client records in four of four client records.
Findings:
Eleven client records were reviewed on January 26, 2009. Four were reviewed as outpatient records. The confidentiality of the client identity and records could not be ensured in client records # 8, 9, 10 and 11. The client records were not being stored on site, but were stored at an alternative location. This location was not a licensed drug and alcohol facility and the confidential storage of client records could not be verified.
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Plan of Correction
1) As of this juncture all outpatient records have been moved from the Erie Co Prison satellite to this facility where they remain under double lock in the administration office. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on the review of client records, the facility failed to document that clients were informed of their rights in four of four client records.
Findings:
Eleven client records were reviewed on January 20-21, 2009. Four client records were reviewed as outpatient records. Four client records were required to document that the client was informed of their rights. There was no documentation that the clients were informed of their rights in client records # 8, 9, 10 and 11.
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Plan of Correction
In practice the patients are given a standard Gateway Rehabilitation Notification of Rights. The problem was in the documentation of the receipt. As of 01/30/2009 the therapist at the Erie County Prison has a modified check list that the patient signs indicating that they have received a copy of their Patient Right. The therapist and the Patient sign off on this document and the document is entered into the permanant record. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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 the review of client records, the facility failed to develop an individual treatment and rehabilitation plan in four of four records.
Findings:
Eleven client records were reviewed on January 20-21, 2009. Four client records were reviewed as outpatient records. Four client records were required to have an individual treatment and rehabilitation plan. There was no documentation that an individual treatment and rehabilitation plan was developed in client records # 8, 9, 10 and 11.
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Plan of Correction
During the inspection both the Clinical Supervisor and the Examiner failed to identify the treatment plan.
Once the Inspection was completed the Therapist pointed out that the document was present on the back of a document that lists the multi-axial diagnosis. Further examination indicated that the supervisor had indeed signed of on the document; so, it was a mere lapse in his ability to identify the Tx plan during the inspection. |
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 the review of client records, the facility failed to document that an updated treatment and rehabilitation plan had been completed at least every 60 days in one of one client record.
Findings:
Eleven client records were reviewed on January 20-21, 2009. Four client records were reviewed as outpatient records. One client record was required to have an updated individual treatment and rehabilitation plan. There was no documentation that an updated individual treatment and rehabilitation plan was completed in client record # 9.
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Plan of Correction
1) The Program Director and the Administrative Assistant will conduct monthly Chart Reviews to determine presence and timeliness of required documentation.
2)Deficiencies will be noted and a memo will be given to the clinician for correction.
3) The following month the previous deficiencies will be reviewed for correction.
4) If not corrected the clinician will face disciplinary actions. |