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 28, 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 Erie 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 document TB/STD training within the required timeframes in four staff records.Employee #7 was hired as support staff on January 29, 2018. TB/STD training was due to be completed by January 29, 2020. At the time of the inspection, there was no documentation that Employee #7 completed TB/STD training.Employee #8 was hired as maintenance staff on March 6, 2017. TB/STD training was due to be completed by March 6, 2019. At the time of the inspection, there was no documentation that Employee #8 completed TB/STD training.Employee #9 was hired as support staff on February 12, 2018. TB/STD training was due to be completed by February 12, 2020. At the time of the inspection, there was no documentation that Employee #9 completed TB/STD training.Employee #10 was hired as support staff on March 28, 2018. TB/STD training was due to be completed by March 28, 2020. At the time of the inspection, there was no documentation that Employee #10 completed TB/STD training.These findings were reviewed with facility staff during the licensing process.This is a repeat deficiency from the 2019 licensing inspection.
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Plan of Correction
Gateway will be offering, per DDAP bulletin, HIV/AIDS training available quarterly to its employees. In addition Gateway will utilize the online DDAP approved offerings for HIV/AIDS. The employees will be required to sign up and complete the next feasible HIV/AIDS training. Custody and Control Coordinator, Maintenance Tech and two therapists, completed training on 9/24/2020. All staff with complete the mandatory TB/STD training within the required timeframes..
Managers of this site will ensure staff training is completed as required by logging training 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 Hman Resources will remind all staff to check their training's 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 at least 25 hours of training for each counselor for the 2019 training year.Employee #3 was hired as a counselor on November 5, 2007. Employee #3 had documentation of 12.5 hours of training for the 2019 training year.Employee #4 was hired as a counselor on December 11, 2017. Employee #4 had documentation of 1.5 hours of training for the 2019 training year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee will ensure that they have received all 25 hours of training each year. The manager will meet with the employee to review the planned training hours for the year to ensure meeting the regulation.
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.Employee #6 was hired as a counselor on December 30, 2019. The fire extinguisher training was documented on January 15, 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 use, and emergency training upon employment. HR staff will monitor completion of orientation checklist detailing completion of these two training's.
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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