INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19th 2018 of Gateway Greensburg by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #5 hired 2/6/17 as a counselor received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #5 is missing the required 6 hours of HIV/AIDS training within a year of hire. Employee #5 will sign up for and complete the next feasible HIV/AIDS training.
The director of outpatient services and manager of the Greensburg site will monitor to ensure this training is complete. In addition, Human Resources will send quarterly reminders to all managers reminding them to review the Human Resources training spreadsheet. This reminder will also include time parameters for DDAP required trainings
This deficiency will be corrected by December 31, 2018 |
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 the completion of 25 clock hours of annual training required for counselors in employee #3's employee record.
Employee #2 was hired as a counselor on June 27, 2005 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2017 to December 31, 2017 Employee #3's employee record only documented 24.75 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Employee #3 will ensure she has received all 25 hours of training for 2018. Her manager will meet with her to review the planned training hours for the year to ensure meeting the regulation. The director of outpatient services and manager of the Greensburg site will monitor to ensure this training is complete. This deficiency will be corrected immediately. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The Facility failed to document an annual written individual staff performance evaluation for staff in employee #1's employee record.
Employee #1 was hired 5/2/2000 and still employeed as project director at the time of the inspection. Employee #1's record failed to contain an annual proformance review for 2017.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
All Vice Presidents will receive a yearly PE in October.
The VP of human resources will monitor completion of yearly PEs.
This deficiency will be corrected by October 31, 2018. |