INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on October 27, 2021 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/training records, the facility failed to provide documentation staff persons received a minimum of 6 hours of HIV/AIDS and 4 hours of TB/STD training in two of seven records reviewed.
Staff #6 was hired as a counselor assistant on February 3, 2020. HIV/AIDS and TB/STD training was due to be completed by February 3, 2021. There was no documentation HIV/AIDS or TB/STD training in staff record #6.
Staff #7 was hired as a counselor assistant on July 27, 2020. HIV/AIDS and TB/STD training was due to be completed by July 27, 2021. There was no documentation HIV/AIDS training in staff record #7.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the August 24, 2020, October 25, 2019 and October 11, 2018 licensing inspections.
|
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 and TB/STD training.
The nursing supervisor will be providing training at Gateway Rehab and will use the DDAP curriculum for both HIV/AIDS, STD/TB. These trainings will be offered monthly.
The employees will be required to sign up and complete the next HIV/AIDS and TB/STD training.
In order to satisfy the deficiencies that we currently have, we have secured training for the employees listed below.
The following employees will be registered to attend Communicable Disease Training on the following dates:
Dec 1-2 (Virtual), Dec 8-9 (virtual), Jan 5-6 (virtual), Jan 10-11 (Virtual), and Feb 3-4 (Virtual).
Staff 6
Staff 7
The VP of Recovery Service reminded all staff present at the Enterprise Management Meeting of October 29, 2021 that Mandatory Communicable Disease Training (HIV/AIDS & TB/STD are required trainings and must be completed by counselors and counselor assistants within the first year of employment. All other staff must complete Communicable Disease Trainings within the first two years of employment and to share this licensure requirement with all applicable staff.
Because this is a repeat deficiency, the Compliance Officer and VP of Human Resources will be conducting a monthly audit of all "active" Training Records to ensure compliance with Mandatory Communicable Disease Training.
Counselors and Counselor assistants will be required to register and attend the HIV/AIDS & TB/STD Training that is offered immediately following their hire date. If this session is full then they will be required to register and attend the next HIV/AIDs & TB/STB Training.
Training Record Audit results will be forwarded to the Manager, Program Director, applicable Vice President for corrective action.
Staff that do not comply with this licensing requirement and their direct Manager will be subject to progressive discipline and will not be eligible for performance evaluation increases.
Training Record Audit results will also be shared at the Quarterly Compliance Meeting.
|
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 correction approved by the Department.
The facility received citations for Mandatory Communicable Disease training during the annual licensing inspections on October 11, 2018, October 25, 2019, August 24, 2020 and October 27, 2021.
Plans of correction to gain compliance were completed by facility staff for the 2018, 2019 and 2020 and approved by DDAP staff; however, the facility remains out of compliance.
These findings were reviewed with facility staff during the licensing process.
|
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 and TB/STD training.
The nursing supervisor will be providing training at Gateway Rehab and will use the DDAP curriculum for both HIV/AIDS, STD/TB. These trainings will be offered monthly.
The employees will be required to sign up and complete the next HIV/AIDS and TB/STD training.
In order to satisfy the deficiencies that we currently have, we have secured training for the employees listed below.
The VP of Recovery Service reminded all staff present at the Enterprise Management Meeting of October 29, 2021 that Mandatory Communicable Disease Training (HIV/AIDS & TB/STD are required trainings and must be completed by counselors and counselor assistants within the first year of employment. All other staff must complete Communicable Disease Trainings within the first two years of employment and to share this licensure requirement with all applicable staff.
Because this is a repeat deficiency, the Compliance Officer and VP of Human Resources will be conducting a monthly audit of all "active" Training Records to ensure compliance with Mandatory Communicable Disease Training.
Counselors and Counselor assistants will be required to register and attend the HIV/AIDS & TB/STD Training that is offered immediately following their hire date. If this session is full then they will be required to register and attend the next HIV/AIDs & TB/STB Training.
Training Record Audit results will be forwarded to the Manager, Program Director, applicable Vice President for corrective action.
Staff that do not comply with this licensing requirement and their direct Manager will be subject to progressive discipline and will not be eligible for performance evaluation increases.
Training Record Audit results will also be shared at the Quarterly Compliance Meeting.
|