INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Squirrel Hill 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 29, 2008.
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Plan of Correction
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on the review of personnel records, the facility failed to provide documentation of close supervision of the counselor assistant for at least the first six months of her employment. Refer to employee record #4.
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Plan of Correction
- (The Clinical Manager recently return to work from an extended medical leave)
- On March 3, 2008, the Regional Director meet with the Clinical Manager and instructed her on the following three procedures:
1 ? Beginning immediately, the Clinical Manager (or the assigned primary therapist) will consistently document close supervision of all counselor assistants for, at least, the first six months of their employment;
2 ? Beginning immediately, the clicial Manager or delegate will maintain a hard copy file of all supervision notes as well as a computer file of these documents in a shared directory, accessible to the Clinical Manager, Regional Director and Administrative Assistant.
3 ? At least quarterly, the Clinical Manager will provide a report to the Regional Director on the status of all counselor assistances, supervision issues and their respective documentation. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records, the facility failed to develop an individual training plan for one of six employee records, specifically employee record #1.
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Plan of Correction
- The President/CEO will complete an annual training plan for 2008 by February 25. The Vice President of Human Resources will review the plan and Ensure that training hours are completed as scheduled. |
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 the review of personnel records, the facility failed to document that all staff persons received the required minimum training of 6 hours of HIV/AIDS and at least 4 hours of STD/TB training in one of seven employee records reviewed, specifically #7.
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Plan of Correction
- HIV/AIDS and TB/STD trainings are included on the employee's annual training plan.
- This staff member is now scheduled for the HIV/AIDS training on March 26, 2008
- Athough a TB/STD training is not currently available, this stafF member will be scheduled to attend this training by July, 2008
- To ensure closer monitoring of staff trainings, the Clinical Manager will create an on-site file for each staff member, which will include copies of training plans & training records/certificates, and signed performance evaluations.
- The Manager will review these records at the end of each quarter as a aid to assist staff to schedule and complete trainings listed on their annual plans, including required/mandatory trainings. In turn, the Manager will present a quarterly status report to the Regional Director.
- The Manager will compare these records with HR every 6 months to ensure completeness of both files. This will assist the manager to maintain a more hands-on record of the needed trainings for each staff.
- These on-site files on all staff will be constructed by February 11, 2008 and will be maintained thereafter.
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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 training records, the facility failed to document 25 hours of training in two of three records reviewed, #5 and 7. Employee #5 had only 15 hours documented and employee #7 had only 3 hours documented.
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Plan of Correction
- To ensure closer monitoring of staff trainings, the Clinical Manager will create an on-site file for each staff member, which will include copies of training plans & training records/certificates, and signed performance evaluations.
- The Manager will review these records at the end of each quarter as a aid to encourage staff to schedule and complete trainings listed on their annual plans. In turn, the Manager will present a quarterly status report to the Regional Director.
- The Manager will compare these records with HR every 6 months to ensure completeness of both files. This will assist the manager to maintain a more hands-on record of the type and number of training hours for each staff.
- These on-site files on all staff will be constructed by February 11, 2008 and will be maintained thereafter.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based of the results of a physical plant inspection, the facility failed to ventilate the bathrooms with either exhaust fans or windows. There were no exhaust fans or windows in any of the facility's three bathrooms.
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Plan of Correction
- The facility does have constant, building exhaust system. However the staff member escorting the DOH staff on the physical plant tour was unaware of the system.
- The Regional Director will inform all staff of the facility's ventilation system at the March 6, 2008 staff meeting.
- To ensure that all new staff (future hires) know of this system, the Regional Director will add this information to the "New Staff Orientation" procedures and checklist form by March 17, 2008.
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709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in two of four records reviewed, specifically client records #7 and 8. The psychosocial evaluations did not address the client's coping mechanisms. In three of four records reviewed, the counselor's conclusions and impressions were not clinical or evaluative but were historical reiterations of the data collected. Refer to client records #7, 8 and 9.
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Plan of Correction
- In the temporary absence of the Clinical Manager, the Regional Director conducted an in-service training on psychosocial evaluations with all facility staff on February 15, 2008. This in-service included input from the facility staff who consistently prepare well written psychosocial evaluations.
- The Regional Director will conduct case staffings twice monthly with the facility staff, which will include reviews of the psychosocial evaluations of all recently admitted patients, ensuring thorough completion of these documents and staff's understanding and follow-through of such documentation.
- The Clinical Manager will continue these case staffings/chart reviews when she returns from medical leave.
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709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records, the facility failed to complete an aftercare plan for one of one record where the document was required, specifically client record #2.
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Plan of Correction
- In the temporary absence of the Clinical Manager, on February 5, 2008, the Regional Director met with the staff member in question and discussed the medical record procedures for documenting after care plans. Additionally, the Regional Director conducted an in-service training with all facility staff on February 15, 2008 that included a review of these documentation procedures for aftercare planning.
- The Regional Director will conduct case staffings twice monthly with the facility staff, which will include reviews of the aftercare plans or planning needs of all patients, scheduled for discharge within the subsequent week. This will ensure thorough completion of these documents and staff's understanding and follow-through of such documentation.
- The Clinical Manager will continue these case staffings/chart reviews when she returns from medical leave.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information from clients in two of nine client records reviewed, specifically # 4 and 5. Family members and friends of all clients were encouraged to attend family night group sessions. These sessions were conducted as treatment sessions. Clients were identified as drug and alcohol clients in these sessions, but there was no documentation showing that the client's consented to being identified by the attendees who were not clients at the facility. Consent to release information forms were missing in both records.
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Plan of Correction
1.Beginning immediately, all non-patient participants in family group sessions will read and sign a statement that they agree to keep any information they observe or hear in family group confidential, including a reminder of legal repercussions that might ensue if they violate a patient's confidentiality.
2. Beginning March 24, 2008, Gateway will have all patients sign a new consent at admission that informs the patient that, by signing the consent the are authorizing Gateway to release to any participant in the combined family group session who is not a patient, information that includes the patient's presence in treatment and any information that they verbally divulge during the session.
3. The purpose of this release is to allow Gateway to conduct regularly scheduled family group sessions during the course of the patient's treatment.
4. Gateway's Director of Medical Records and the Regional Program Directors will be responsible for the implementation of this plan.
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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 complete a treatment plan update in one of three client records where due. Refer to client record # 3.
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Plan of Correction
- In the temporary absence of the Clinical Manager, on February 5, 2008, the Regional Director met with the staff member in question and discussed the medical record procedures for documenting treatment plan updates. Additionally, the Regional Director conducted an in-service training with all facility staff on February 15, 2008 that included a review of the documentation procedures for Treatment plan updates.
- By March 14, 2008, the Regional Director and Administrative Assistant will prepare a tickler file system to idenity required dates for treatment plan updates on all open cases.
- Afterwards, the Clinical Manager will conduct case staffings twice monthly with the facility staff, which will include reviews of treatment plans and, with the respective treatment staff, will prepare treatment plan updates as required. This will ensure thorough completion of these documents and staff's understanding and follow-through of such documentation.
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