INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, and a buprenorphine monitoring inspection conducted on September 15 - 16, 2016 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.
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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 a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training required for staff in 15 of 19 training records reviewed during the annual licensing inspection conducted on September 15 - 16, 2016.
HIV/AIDS training was not documented for the following staff:
Counselor # 16 was hired on August 3, 2015.
Counselor # 18 was hired on August 17, 2015.
Counselor # 19 was hired on August 10, 2015.
Support staff # 23 was hired on August 12, 2013.
TB/STD training was not documented for the following staff:
Counselor # 17 was hired on August 31, 2015.
Support staff # 20 was hired on August 11, 2014.
Support staff # 21 was hired on May 29, 2012.
Support staff # 24 was hired on November 14, 2011.
Support staff # 25 was hired on July 9, 2012.
Support staff # 27 was hired on August 16, 2010.
Support staff # 28 was hired on September 8, 2014.
Support staff # 29 was hired on March 25, 2013.
Support staff # 30 was hired on January 30, 2012.
Both HIV/AIDS and TB/STD trainings were not documented for the following staff:
Support staff # 22 was hired on March 4, 2014.
Support staff # 26 was hired on January 27, 2014.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the staff who did not have certificates were registered for the 10/27 HIV/AIDs training and a 11/4 TB/STD training. Managers and Directors are responsible for ensuring the completion of the training and forwarding certificates onto HR.
Administrative Assistants will pull training documentation quarterly on clinical staff and provide report to managers to ensure that staff are attending required trainings in required time frames and providing documentation.
managers and Directors without admins are required to ensure that they are monitoring support staff quarterly 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
The facility failed to document at least 25 clock hours of annual training required for counselors for the January 1 - December 31, 2015 training year in three of five training records reviewed during the annual licensing inspection conducted on September 15 - 16, 2016.
Counselor # 14 was hired for the position on August 15, 2013 and completed 9.5 hours of annual training.
Counselor # 31 was hired for the position on June 23, 2008 and completed 9.5 hours of annual training.
Counselor # 32 was hired for the position on October 20, 2009 and completed 5.5 hours of annual training.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new review process was implemented to review the annual training hours for staff. Hours will be reviewed quarterly by the Administrative Assistants and sent to supervisors to review with their staff directly to ensure annual training hours are met and documented appropriately.
Managers and Directors are responsible to ensure that the staff meet the annual training requirements and held accountable. |
709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
The facility failed to document a complete client record in three of ten inpatient records reviewed during the annual licensing inspection on September 15 - 16, 2016.
Follow-up information was not documented in the following client records:
Client # 13 was admitted into treatment on January 19, 2016 and discharged on February 5, 2016.
Client # 14 was admitted into treatment on January 10, 2016 and discharged on February 7, 2016.
Client # 15 was admitted into treatment on February 19, 2016 and discharged on March 20, 2016.
In addition, client records # 13 and 15 did not include documentation of an aftercare plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
beginning 11/1/2016 Follow up calls will be made within 6 months of a patient's regular discharge from Abe's place and Ramsey Hall. Provided there is consent, a follow up call will be made and documented in the pt record by the Administrative assistants of each program, this is a change from previous procedure of follow ups being made by an external depts. The administrative Assistance will track and monitor follow up calls including sending letters when contact is unable to be made, this will allow for more oversight and tracking of follow up calls and allow for documentation of follow up calls to be made in the patient record and not to have external documentation.
Monthly reviews will occur with managers and Admin assistants to monitor that follow up calls are made and documented appropriately
Mangagers and Directors of the programs will be responsible for oversight and accountability.
Aftercare plans are completed as a group and reviewed with each client's individual therapist to be retained in the client record. Aftercare plans or refusal to complete aftercare plans will be documented in the client record in the appropriate group note as well as the aftercare plan itself. |