INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9-11, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center 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
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report form, the facility failed to provide documentation of 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, in five of fourteen personnel training records.
The findings include:
Thirty one personnel training records were reviewed on January 2-4, 2013. Fourteen personnel training records were reviewed for documentation of 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. The facility failed to provide documentation of HIV/AIDS and TB/STD training in personnel training records # 28, 30 and 31. The facility failed to provide documentation of HIV/AIDS training in personnel training record # 24 and 29.
Employee # 24 is a counselor and was hired on May 2, 2011. HIV/AIDS training was due to be completed no later than May 2, 2012. There was no documentation provided that the employee had completed the HIV/AIDS training.
Employee # 28 is a non clinical evening counselor and was hired on July 19, 2010. HIV/AIDS and TB/STD training was due to be completed no later than July 19, 2012. There was no documentation provided that the employee had completed the HIV/AIDS and TB/STD training.
Employee # 29 is a scheduling specialist and was hired on September 13. 2010. HIV/AIDS training was due to be completed no later than September 13, 2012. There was no documentation provided that the employee had completed the HIV/AIDS training.
Employee # 30 is a maintenance technician and was hired on August 16, 2010. HIV/AIDS and TB/STD training was due to be completed no later than August 16, 2012. There was no documentation provided that the employee had completed the HIV/AIDS and TB/STD training.
Employee # 31 is a housekeeper and was hired on November 9, 2009. HIV/AIDS and TB/STD training was due to be completed no later than November 9, 2011. There was no documentation provided that the employee had completed the HIV/AIDS and TB/STD training.
This is a repeat citation from the April 16 -18, 2007, January 14 - January 16, 2008, January 8 - 9, 2009, January 11 - 12, 2010 and December 20 - 21, 2010 and the January 10-12, 2012 inspections.
The Facility Director was interviewed on January 11, 2013 and confirmed the findings.
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Plan of Correction
The 5 staff members that have not completed the Mandatory Communicable Disease trainings will be scheduled immediately and will be in compliance by 6/1/13 (based on training availability). The Department Directors will be responsible to make sure this task is completed. Department Directors, along with the Human Resources Departmetn, will monitor these trainings for all staff on an on-going basis throughout the year. |
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
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in three of thirteen personnel records.
The findings include:
Thirty one personnel records were reviewed on January 1-4, 2013. Eighteen personnel records pertained to counselors. The training year is January- December. The January- December 2012 training year was reviewed. Thirteen personnel records required the completion of 25 clock hours of annual training. The training year is January- December. The January- December 2012 training year was reviewed. The facility failed to document 25 clock hours of annual training in personnel records # 9, 19 and 21.
Employee # 9 was hired as a counselor on August 20, 2011. The employee had 10.5 documented training hours for the 2012 training year.
Employee # 19 was hired as a counselor on January 20, 1990. The employee had 8 documented training hours for the 2012 training year.
Employee # 21 was hired as a counselor on March 29, 2004. The employee had 16.5 documented training hours for the 2012 training year.
The Facility Director was interviewed on January 11, 2013 and confirmed the findings.
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Plan of Correction
Training Plans for 2013 have been completed for all staff, including identifying all necessary clinical training needs and hours. Clinical Managers for each Program will be responsible to make sure the Training Plans are followed and that staff compete the necessary hours of training. Department Directors, along with the Human Resources Department, will monitor this on an on-going basis throughout the year. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection, the facility failed to prohibit facility heaters that were not permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on January 10, 2013 from approximately 1:30 P.M. to 3:54 P.M. During the inspection, a portable space heater was found in an office on the detox unit of the facility. The heater was not permanently mounted or installed.
The Facility Director was present during the inspection and confirmed the findings.
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Plan of Correction
The space heater identified during the licensing inspection was discarded that day. The Director of Environmental Services will monitor that no additional space heaters are used. This will occur on an on-going informal basis, as well as during formal quarterly Environmental Rounds conducted by the Director of Environmental Services. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on observation, the facility failed to maintain the confidentiality of client identity and records.
The findings include:
While walking through the waiting room on January 9, 2013, a conversation taking place in the waiting room was overheard by this licensing specialist. The staff member was discussing with a client his admittance to the detoxification activity. Sitting directly across from the client and staff member was a young couple who could also hear the entire conversation. Persons entering the waiting area could also overhear the conversation.
During the physical plant inspection on January 10, 2013, in a third floor office, confidential client information was in plain view of persons entering the office. The individual was gone for the day. The office was locked, but persons not permitted access to client information do have access to the office.
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Plan of Correction
Since these issues were identified during the licensing inspection, all applicable staff were re-directed and re-educated about finding a private location to discuss confidential information. In addition, each Department Director has re-educated staff about securing information that contains Private Health Information (PHI) in a secure manner in their offices. Department Directors will be responsible to ensure confidentiality is maintained for all patients on an on-going basis. This will be done on an informal basis, as well as during formal Environmental Rounds conducted by Department Directors quarterly. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on observation and a physical plant inspection, the facility failed to secure client records within locked storage containers.
The findings include:
A physical plant inspection was conducted on January 10, 2013. During the inspection of the detoxification unit, an office was found to have client records stored on an open shelf with the full name of the client visible. While the office is staffed during daylight hours and is locked at all times, persons not permitted access to client information have access to the office during hours that the office is not staffed.
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Plan of Correction
Immediately following the licensing inspection, all "active" medical records were removed from the open shelving unit and situated in a closed lateral file that is equipped with a lock. The Director of Medical Records will ensure that compliance with securing "active" medical records is maintained through formal and informal inspections on an on-going basis. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of two client records.
The findings include:
Thirty three client records were reviewed on January 7-11, 2013. Twenty three client records reviewed were records of discharged clients. Two of the discharged clients were involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 15.
Client # 15 was admitted into treatment on November 15, 2012 and was involuntarily terminated from the project on November 18, 2012. The written notification documented in the file had not been signed by the client. There was no documentation provided that the client had been notified, in writing, of the decision to involuntarily terminate the client's treatment at the project.
The Facility Director was interviewed on January 11, 2013 and confirmed the findings.
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Plan of Correction
By policy, a copy of the Termination of Treatment forms are mailed to the any client that does not receive a copy at the time of discharge. This information is documented on the Termination of Treatment form.
The in-patient staff member that completed the Termination of Treatment form for Client #15 used an out-dated form and did not follow the policy.
All out-dated Termination of Treatment forms have been discarded.
All in-patient staff were re-trained in January 2013 regarding how to complete Termination of Treatment forms correctly. These forms, and their completeness, will be monitored on an on-going basis by the Medical Records Department during a formal review of each medical record after discharge. The Department Director will be alerted immediately to any issues with the completion of the form and will follow up with the specific staff member and provide instruction when necessary. The Director of Medical Records and Department Director will ensure this process is taking place on an on-going basis.
The Facility Director has ensured this issue was corrected by 2/1/13. The Facility Director, along with the Department Directors stated above, will ensure the POC is followed on an on-going basis through informal audits during treatment and formal audits after discharge. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document psychosocial evaluations that provided a clinical evaluation that included a composite picture of the client, the client's problems and needs to be addressed in treatment, the client's assets and strengths, the client's support systems, the client's coping mechanisms, the negative factors that might inhibit treatment, and the counselor's impressions regarding the client in four of fourteen client records.
The findings included:
Thirty three client records were reviewed on January 7-11, 2013. Twenty two records reviewed were inpatient client records. Fourteen client records were reviewed for the content of a psychosocial evaluation. The psychosocial evaluation did not include a clinical evaluation that included a composite picture of the client, the client's problems and needs to be addressed in treatment, the client's assets and strengths, the client's support systems, the client's coping mechanisms, the negative factors that might inhibit treatment, the client's attitude towards treatment and the counselor's conclusions/impressions regarding the client in client records # 23, 24, 27 and 30.
Client # 23 was admitted on October 24, 2012 and discharged on November 13, 2012. The psychosocial evaluation, dated October 25, 2012, had not been completed and was missing the composite picture of the client, the client's assets and strengths, the client's coping mechanisms, the client's attitude towards treatment and the counselor's conclusions/impressions regarding the client.
Client # 24 was admitted on October 23, 2012. The psychosocial evaluation, dated October 25, 2012, consisted of client reported information and did not include a clinical evaluation of the client's assets and strengths, the client's support systems, the client's coping mechanisms, the negative factors that might inhibit treatment, the client's attitude towards treatment or the counselor's conclusions/impressions regarding the client.
Client # 27 was admitted on December 28, 2012. The psychosocial evaluation, dated December 24, 2012, consisted of client reported information and did not include a clinical evaluation of the client's assets and strengths, the client's coping mechanisms, the client's attitude towards treatment or the counselor's conclusions/impressions regarding the client.
Client # 30 was admitted to inpatient on November 1, 2012. The psychosocial evaluation, dated September 28, 2012, consisted of client reported information and did not include a clinical evaluation of the client's assets and strengths, the client's coping mechanisms or the client's attitude towards treatment.
The Facility Director was interviewed on January 11, 2013 and did not dispute the findings.
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Plan of Correction
A review training with all rehab clinical staff will be conducted by 2/18/13 regarding how to complete psychosocial evaluations correctly. These forms, and their completeness, will be monitored on an on-going basis by the Department Clinical Managers and will include follow up with specific staff when necessary to provide individual direction. The Department Directors will ensure this process is taking place on an on-going basis. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information in one of three client records.
The findings include:
Thirty three client records were reviewed on January 7-11, 2013. Three client records were reviewed as discharged outpatient records and required follow-up information. Per agency policy, follow-up is to be completed within 6 months of discharge. The facility failed to document follow-up information in client record # 33.
Client # 33 was admitted on November 28, 2011 and discharged on February 29, 2012. Follow-up was to be completed by August 29, 2012. There was no follow up contact documented in client record # 33.
The Facility Director was interviewed on January 11, 2013 and confirmed the findings.
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Plan of Correction
Since GRC is not currently providing out-patient services at Main Campus, this issue is resolved. Upon offering out-patient services at Main Campus in the future, the Department Director, along with the Director of Research, will train appropriate staff to follow the policy, including making follow-up calls. This process will be monitored on an on-going basis by the Department Director responsible for out-patient services at Main Campus. |