INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 20, 2018 of Gatway Rehabiliation Squirrel Hill 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, Gatway Rehabiliation 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:
|
Plan of Correction
|
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.
|
Observations
The facility failed to ensure that employee #7 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #7 was hired as a Counselor on 08/21/2017 and was due to have the communicable disease trainings no later than 8/21/18. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Employee #7 will sign up for and complete the next feasible HIV/AIDS and TB/STD trainings. The director of outpatient services and manager of the Squirrel Hill 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 March 31, 2019. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
The facility failed to conduct an unannounced drills during March 2018.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Manager will develop a reminder mechanism to ensure unannounced fire drills will be performed monthly. The director of outpatient services will monitor monthly completion of fire drills. 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.
|
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
|
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. |
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.
|
Observations
The facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record #4. Additionally, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client records #'s 13 and 14.
Client #4 was admitted on 08/3/2017 and was still an active client at the time of the inspection. There was documentation that a treatment letter was faxed to and individual on 08/13/18; however, there was no consent to release information form signed by the client prior to disclosure.
Client#13 was admitted on 3/28/18 and was discharged on 5/2/18. A consent to release form was signed and dated on 3/29/18 to the funding source that allowed for the release of diagnostic assessment information, diagnoses, discharge summary/planning and other.
Client#14 was admitted on 5/29/18 and was discharged on 6/19/18. A consent to release form was signed and dated on 3/8/18 to the funding source that allowed for the release of progress notes, diagnostic assessment information, lab results, urine testing, medication and other.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Health Information Management will re-educate the applicable Administrative Assistant staff on confidentiality issues namely PA Code 255.5 (b) and proper completion of Release of Information Forms. The Director of Health Information will review and monitor compliance on a weekly basis for one month, and then monthly for six months, a total of seven months. An in-service training that addresses proper completion of Release of Information Forms will be scheduled within four months. Audit findings will be reviewed with Program Directors and Clinical Managers as well as the Risk Management Committee. |