INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 24, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Gateway Rehabilitation Center - Mount Pleasant 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 provide documentation that staff persons received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training in two of four personnel/training records reviewed.
Employee # 8 was hired August 6, 2018 for the position of counselor.
Employee # 10 was hired July 22, 2019 for the position of counselor assistant.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2018 and 2019 licensing inspections.
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Plan of Correction
Employee #8 is scheduled to attend HIV/AID training on 9/24/20. Upon receiving certificate employee will submit copy to GRC HR dept. Employee #10 attended HIV/AID training on 8/31/20. She submitted certificate to GRC HR dept.
Gateway will be offering, per DDAP bulletin, HIV/AIDS training available quarterly to its employees. In addition Gateway will utlize the online DDAP approved offerings for HIV/AIDS. The employees will be required to sign up and complete the next feasible HIV/AIDS training.
Managers of each site will ensure staff training is completed as required by logging trainings into spreadsheet that is reviewed monthly during supervision with the employee(s). Director will conduct monthly random training documentation checks.
All managerial staff will be educated by 10/15 as to the requirement of monthly review with staff during supervision. Training discussion should be logged in supervision documentation. Director will do random training checks on all new staff every 2 months. VP of Human Resources will remind all staff to check their trainings monthly and share applicable in house and DDAP webinar trainings as they are scheduled.
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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
The facility failed to document each counselor completed at least 25 clock hours of annual training for the January - December 2019 training year in employee record # 8.
Employee # 8 was hired August 6, 2018 for the position of counselor. Only 3 training hours were documented for the 2019 training year.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2019 licensing inspection.
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Plan of Correction
Employee #8 will ensure to have received 25 required trainings hours in 2020. The manager will meet with the employee to reviewing training plan ensuring that it meets required regulations.
The site manager will meet with all facility staff reviewing their training plans ensuring that they meet required hours based on their position.
Site manager, program director, and Vice President of Human Resources will monitor non-compliant staff to ensure
they have received required training.
Managerial staff will be re-educated by 10/15/20. HR staff will begin monitoring immediately |
704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
The facility failed to document each counselor assistant completed at least 40 clock hours of training in their first year in employee record # 10.
Employee # 10 was hired July 22, 2019 for the position of counselor assistant. Only 15 training hours were documented in their first year.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #10 will ensure to have received all required trainings hours in 2020. The manager will meet with the employee to reviewing training plan ensuring that it meets required training hours.
The site manager will meet with all facility staff reviewing their training plans ensuring that they meet required hours based on their position.
Site manager, program director, and Vice President of Human Resources will monitor non-compliant staff to ensure
they have received required training.
Managerial staff will be re-educated by 10/15/20. HR staff will begin monitoring immediately.
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
The facility failed to document fire extinguisher training upon staff employment in employee record # 4.
Employee # 4 was hired February 3, 2020. Fire extinguisher training was not documented until February 14, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All managerial staff will be re-educated on the need to orient staff to fire extinguisher location and use, and emergency training upon employment. HR staff will monitor completion of orientation checklist detailing completion of these two trainings.
Site manager, program director, and Vice President of Human Resources will monitor all new staff to ensure they have received required training.
Managerial staff will be re-educated by 10/15/20. HR staff will begin monitoring immediately.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
The facility failed to document that all personnel on all shifts were trained to perform assigned tasks during emergencies in employee record # 4.
Employee # 4 did not have documentation of emergency training upon employment for their assigned shift.
Employee # 4 was hired February 3, 2020. Emergency training was not documented until February 14, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All managerial staff will be re-educated on the need to orient staff to fire extinguisher location and emergency training within seven days of hire. HR staff will monitor completion of orientation checklist detailing completion of these two trainings.
Site manager, program director, and Vice President of Human Resources will monitor all new staff to ensure they have received required training.
Managerial staff will be re-educated by 10/15/20. HR staff will begin monitoring immediately.
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
The facility failed to document the use of alternate exits during monthly fire drills based on a review of the November 2019 through July 2020 fire drill records.
The main front entrance was the only exit route utilized for every fire drill from November 2019 through July 2020.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2019 licensing inspection.
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Plan of Correction
Staff will begin to use hospital exits at least every other months for fire drills.
Director will ensure that reminders are sent monthly to complete the fire drill exercise using different exits.
VP, of Operations will spot check fire drills each quarter
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