INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29-30, 2021 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 staff training records, the facility failed to document that staff persons completed HIV/AIDS and/or TB/STD training within the required timeframe in eight of fifteen records.
Staff #14 was hired as a support staff on August 20, 2018 and promoted to a counselor assistant on June 27, 2021. HIV/AIDS and TB/STD training was due to be completed by August 20, 2020. There was no documentation of HIV/AIDS training in staff record #14.
Staff #15 was hired as a counselor assistant on July 13, 2020. HIV/AIDS and TB/STD training was due to be completed by July 13, 2021. There was no documentation of HIV/AIDS or TB/STD training in staff record #15.
Staff #16 was hired as a counselor assistant on July 13, 2020. HIV/AIDS and TB/STD training was due to be completed by July 13, 2021. There was no documentation of HIV/AIDS or TB/STD training in staff record #16.
Staff #18 was hired as a counselor assistant on November 5, 2018. HIV/AIDS and TB/STD training was due to be completed by November 8, 2020. There was no documentation of HIV/AIDS training in staff record #18.
Staff #19 was hired as a counselor assistant on June 19, 2017. HIV/AIDS and TB/STD training was due to be completed by June 19, 2019. There was no documentation of HIV/AIDS training in staff record #19.
Staff #20 was hired as a counselor assistant on September 11, 2017. HIV/AIDS and TB/STD training was due to be completed by September 11, 2019. There was no documentation of HIV/AIDS training in staff record #20.
Staff #21 was hired as a counselor assistant on April 14, 2016. HIV/AIDS and TB/STD training was due to be completed by April 14, 2018. There was no documentation of HIV/AIDS training in staff record #21.
Staff #22 was hired as a counselor assistant on September 11, 2017. HIV/AIDS and TB/STD training was due to be completed by September 11, 2019. There was no documentation of HIV/AIDS training in staff record #22.
This is a repeat deficiency from the August 24, 2020, October 9, 2019, and September 19, 2018 licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway will be offering, per DDAP bulletin, HIV/AIDS training available quarterly to its employees. In addition, Gateway will utilize the online DDAP approved offerings for HIV/AIDS and TB/STD training.
The nursing supervisor will be providing training at Gateway Rehab and will use the DDAP curriculum for both HIV/AIDS, STD/TB. These trainings will be offered monthly.
The employees will be required to sign up and complete the next HIV/AIDS and TB/STD training.
In order to satisfy the deficiencies that we currently have, we have secured training for the employees listed below.
The following employees will be registered to attend Communicable Disease Training on the following dates:
Dec 1-2 (Virtual), Dec 8-9 (virtual), Jan 5-6 (virtual), Jan 10-11 (Virtual), and Feb 3-4 (Virtual).
Staff 14
Staff 15
Staff 16
Staff 18
Staff 19
Staff 20
Staff 21
Staff 22
The VP of Recovery Service reminded all staff present at the Enterprise Management Meeting of October 29, 2021 that Mandatory Communicable Disease Training (HIV/AIDS & TB/STD are required trainings and must be completed by counselors and counselor assistants within the first year of employment. All other staff must complete Communicable Disease Trainings within the first two years of employment and to share this licensure requirement with all applicable staff.
Because this is a repeat deficiency, the Compliance Officer and VP of Human Resources will be conducting a monthly audit of all "active" Training Records to ensure compliance with Mandatory Communicable Disease Training.
Counselors and Counselor assistants will be required to register and attend the HIV/AIDS & TB/STD Training that is offered immediately following their hire date. If this session is full then they will be required to register and attend the next HIV/AIDs & TB/STB Training.
Training Record Audit results will be forwarded to the Manager, Program Director, applicable Vice President for corrective action.
Staff that do not comply with this licensing requirement and their direct Manager will be subject to progressive discipline and will not be eligible for performance evaluation increases.
Training Record Audit results will also be shared at the Quarterly Compliance Meeting.
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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 a review of staff training records, the facility failed to document each counselor completed at least 25 hours of training for January - December 2020 in two of three records.
Staff #9 was hired as a counselor on November 11, 2015. Staff #9 had documentation of 10.25 hours of training for the 2020 training year.
Staff #10 was hired as a counselor on March 13, 2006. Staff #10 had documentation of 10 hours of training for the 2020 training year.
This is a repeat deficiency from the August 24, 2020 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Gateway will utilize the online DDAP approved offerings for Training Hours required by Counselors and Counselor Assistants.
One time per month, Managers will provide a 1 hour training to all staff. If a staff person is not present, they will be required to make up at a different time.
The employees will be required to sign up and complete the required trainings that they have not complied with to date.
In order to satisfy the deficiencies that we currently have, we have secured training for the employees listed below.
Staff #9 needs 14.75 hours
Staff #10 needs 15 hours
The VP of Recovery Service reminded all staff present at the Enterprise Management Meeting of October 29, 2021 of the 25 Hour Training Requirement for Counselors.
Because this is a repeat deficiency, the Compliance Officer and VP of Human Resources will be conducting a monthly audit of all "active" Training Records to ensure compliance with 25 hours of training for Counselors.
Counselors will be required to register and attend the 25 clock hours of training yearly.
Training Plans will be reviewed by the Clinical Manager monthly with the Employee during supervision to ensure that all applicable trainings are scheduled and attended.
Training Record Audit results will be forwarded to the Manager, Program Director, applicable Vice President for corrective action.
Staff that do not comply with this licensing requirement and their direct Manager will be subject to progressive discipline and will not be eligible for performance evaluation increases.
Training Record Audit results will also be shared at the Quarterly Compliance Meeting.
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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 keep the facility free of heaters that are not permanently mounted or installed.
The physical plant inspection was conducted on September 30, 2021. At the time of the inspection, a portable heater was observed in the "gift shop" area of the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The space heater identified during the licensing inspection in the Gift Shop was immediately discarded that day. The Director of Compliance Officer immediately conducted a walk-through to ensure that there were no more space heater being used.
The VP of Recovery Service reminded all staff present at the Enterprise Management Meeting of October 29, 2021 that Space Heaters are prohibited and to share this licensure requirement with all applicable staff.
The Director of Environmental Services and the Compliance Officer will monitor that residential programs have no evidence of space heaters on a routine regular basis; including quarterly Environmental Rounds.
Environmental Rounds are entered into D3 and findings are reported to the Quarterly Risk Management Meeting.
Completion Date: 11/1/2021 |