INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 24 - 25, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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.
|
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 document HIV/AIDS and TB/STD training in two of two personnel records reviewed.
Employee # 4 was hired for the position of counselor on August 6, 2018. There was no documentation of HIV/AIDS and TB/STD training in employee record # 4.
Employee # 6 was hired for the position of counselor on October 10, 2016. There was no documentation of TB/STD training in employee record # 6.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the 2018 licensing inspection.
|
Plan of Correction
Employee #6 was hired on October 10, 2016 and was due to complete the communicable disease trainings no later than October 10, 2017. There is no documentation of the completion of the TB/STD training in the employee's personnel file as of the date of the inspection. Employee #6 has registered and will attend the TB/STD/Hepatitis training on December 18, 2019.
Employee #4 was hired on August 6, 2018 and was due to complete the communicable disease trainings no later than August 6, 2019. There is no documentation of the completion of the HIV/AIDS or TB/STD trainings in the employee's personnel record as of the date of the inspection. Employee #4 has registered and will attend the Basic HIV training on December 17, 2019 and TB/STD/Hepatitis on December 18, 2019.
To ensure staff at Gateway Rehab receives the training for Communicable Disease that is required within 365 days of hire for all employees, Gateway Rehab designated trainer will use the DDAP approved curriculum for TB/STD and HIV/AIDS (Licensing Alert 6.1997). Gateway Rehab will offer this training one time every two months starting January 1, 2020 to ensure that all staff have the opportunity for training.
The Program Director of the Westmoreland site will monitor to ensure that the trainings are completed.
This deficiency will be corrected by January 1, 2020.
|
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.
|
Observations
The facility failed to document 25 clock hours of annual training required for counselors in one of three personnel records reviewed.
Employee # 3 was hired for the position of counselor on August 1, 2016. The facility's training year is January - December 2018. Employee # 3 only had 21 clock hours of training documented for the 2018 training year.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #3 only has 21 clock hours of training documented for the January - December 2018 training year.
The Program Director will meet with the employee to review the planned training hours for the year to ensure that the employee is meeting the Annual Training Requirements.
The Program Director will monitor to ensure that all training hours are completed and documentation of the completion will be available.
This deficiency will be corrected immediately. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
The facility failed to document a fire drill during sleep hours at least every six months based on a review of the October 2018 through September 2019 fire drill records on October 24, 2019.
The sleep hours for clients are 11:30 PM through 7 AM. Fire drills during sleep hours were only conducted January 2019 and August 2019.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 2018 licensing inspection.
|
Plan of Correction
A fire drill was not conducted during sleep hours at least every six months based on the 2018 -2019 review period.
The Program Director will follow a reminder process to ensure that fire drills during sleep hours are conducted at minimum once every six months.The Program Director will monitor the completion of the fire drills.
This deficiency will be corrected immediately. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
|
Observations
The facility failed to document the use of alternate exits during monthly drills from October 2018 through September 2019 based on a review of fire drill records on October 24, 2019.
The fire drill records indicated that the front exit was utilized for every fire drill.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Alternative exits were not utilized for the fire drills during this review period.
A Request for Exception was submitted for Gateway Rehab-Westmoreland #657055. There are three possible exit routes from the unit for fire drills: 1. Front exit 2. Frick Hospital Main hospital exit - the hospital does not want Gateway Rehab to use the main hospital as an exit route during fire drills. 3. Another exit route that requires patients to exit through the back of the unit and down sets of stairs. This may be difficult for detox patients and patients with disabilities.
The front exit will continue to be utilized for fire drills until a decision is made regarding the Request for Exception.
The Program Director will monitor the results of each fire drill based on the decision and recommendation of the Request for Exception. If the exception is not granted the facility will ensure that alternative exit routes are used during fire drills.
This deficiency will be corrected by 12/31/19. |