INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 7-11, 2022 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 -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:
|
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
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #10 was hired as a counselor assistant on February 17, 2021 and was still employed in that position. Employee #10 was due to have the communicable disease trainings no later than February 17, 2022. Employee #10 received HIV/AIDS training on August 26, 2022, and STD/TB training on August 25, 2022.
This is a repeat citation from October 24-25, 2019, August 24, 2020, and October 27, 2021 1icensing inspections.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All relevant staff will review the DDAP 704.11 (c )(1) regulation by November 16, 2022. The new hire orientation process will be amended to include HIV/AIDS and TB/STD training. The training coordinator will be responsible for coordinating the new hire orientation training period and the communicable disease training. The training will be completed within the first 3 days of hire before the new employee will report to their job duties. The training coordinator is responsible for communicating the completion of these trainings to the responsible clinical manager and director after each new hire class.
This new process will be implemented by November 21, 2022. |
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.
|
Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 40 clock hours of annual training required for counselor assistants.
Employee #10 was hired as a counselor assistant on February 17, 2021 and was still in the position as of the date of the onsite inspection. The training period that was reviewed was from February 17, 2021 through February 17, 2022. Employee # 10's record only documented 31 hours and 45 minutes of annual training for the training year reviewed.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All relevant staff will review the DDAP 704.11(g)(1) regulation by 11/25/22. They will sign off on their understanding of the requirement for yearly 40 clock hour annual training for all counselor assistants. The training coordinator will audit training hours for all staff monthly and send an updated training chart to the clinical managers and directors of each location.
During supervision, the clinical manager and/or director will review the monthly clock hours and document on the supervision form that the training hours were discussed.
Once a month, there will be a minimum of 2 hour all staff training at each location during a staff meeting to add to staff training hours for the year.
The clinical managers and directors will be educated by November 15, 2022 on the new training audit process and will be implemented by December 1, 2022. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling rooms identified as room #104, large group room 2 and large group room 3.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Gateway Rehabilitation Center will request the waiver to allow cameras in the group rooms by December 1, 2022.
If the waiver is denied by DDAP, Gateway Rehabilitation Center will remove the cameras in the group rooms within 5 business days of receiving the denial. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in one out of fourteen records reviewed.
Client #7 was admitted on June 14, 2022 and discharged on June 20, 2022. A consent form dated June 17, 2022 did not identify the name of the person, agency or organization to whom the disclosure is made.
This finding was reviewed with facility staff during the licensing inspection
|
Plan of Correction
The Release of Information shall be in writing and specify the name of the organization to whom the disclosure is made.
The Regional Director of Health Information Management shall re-educate all applicable staff on completing the ROI workflow by November 30, 2022.
The Supervisor of Health Information Management shall audit the Release of Information and share audit results with applicable Program Directors. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
The facility failed to comply with plans of corrections approved by the department. The facility received citations for Mandatory Communicable Disease training during the annual licensing inspections on October 24-25, 2019, August 24, 2020, and October 27, 2021. Plans of corrections to gain compliance were completed by facility staff for the 2019, 2020 and 2021 and approved by DDAP staff; however, the facility remains out of compliance.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All relevant staff will review the DDAP 704.11 (c )(1) regulation by November 16, 2022. The new hire orientation process will be amended to include HIV/AIDS and TB/STD training. The training coordinator will be responsible for coordinating the new hire orientation training period and the communicable disease training. The training will be completed within the first 3 days of hire before the new employee will report to their job duties. The training coordinator is responsible for communicating the completion of these trainings to the responsible clinical manager and director after each new hire class.
This new process will be implemented by November 21, 2022. |