INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on January 25, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Gateway Greensburg 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel training records, the facility failed to document individual training plans by December of each year, as per facility policy, in four of four personnel records.
The findings include:
Nine personnel training records were reviewed on January 3 - 5, 2012. Two of the training records reviewed pertained to new employees and their training plan was completed in the middle of the facility training year. Per facility policy, training plans will be completed by the end of each year in December. The facility's training year is from January through December. Training plans were reviewed for the 2011 training year and were due to be completed no later than December 31, 2010.
The facility failed to document individual training plans by December 31, 2010 in personnel training records # 1, 2, 3, 4, 6, 8 and 9. Training plans for these employees were completed between January 25 and May 26, 2011. Personnel record # 8 did not contain an individual training plan.
The facility director and human resources director were interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
As a result of the recent licensing visit, Gateway Rehab's Policy and Procedure for Staff Training and Development was changed. The new P & P states that training year will be from February 1 to January 31. Therefore the 2012 - 2013 training year begin February 1, 2012 and ends January 31, 2013.
The change also specifically states that supervisory staff will develop an annual training plan for each of the employees in their department. The calendar includes individual training needs, the topics and number of hours of training required by various outside sources, licensing and regulatory groups, and internal and external training events. The Human Resources staff will assist the supervisors in the development of these training calendars.
The 2012 calendars were forwarded to the supervisory staff were due by 2/1/2012.
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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 records, the facility failed to document TB/STD training in one of five personnel records.
The findings include:
Nine personnel records were reviewed on January 3-5, 2012. Five staff records were reviewed for documentation of HIV/AIDS and TB/STD training. Per regulation, 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. The facility failed to document TB/STD training in personnel record # 8.
Employee # 8 is a counselor and was hired on May 29, 2007. A Department approved curriculum in TB/STD training was due to be completed no later than May 29, 2008. There was no documentation of completion of TB/STD training in personnel record #8.
Interviews with human resources staff, facility director and clinical supervisor took place at various times throughout the licensing inspection. It was confirmed that there was no documentation of TB/STD training for employee #8.
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Plan of Correction
Employee #8 is a PRN clinical staff member who has not been available to work for a number of months. She also reports not being available to work during the next 2 months.
The employee knows that she will need to complete the manatory TB/STD before being scheduled to work again. The Director or Clinical Manager will inform the employee of this training event as it come available. The plan is for her to complete the training by June, 2012. |
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 two of six personnel records.
The findings include:
Nine personnel records were reviewed on January 3-5, 2012. Six personnel records pertained to counselors and required the documentation of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel records # 6 and 8.
Employee # 6 was hired on May 5, 2008. The facility training year is from January through December. Employee # 6 had documentation of six hours of training for the 2011 training year.
Employee # 8 was hired on May 29, 2007. The facility training year is from January through December. Employee # 8 had no documentation of training completed in the 2011 training year.
Interviews with human resources personnel, facility director and clinical supervisor took place at various times throughout the licensing inspection. It was reported that employee #6 went on approved leave as of October 21, 2011. The aforementioned completed training hours were confirmed during these interviews.
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Plan of Correction
To ensure closer monitoring of staff trainings, the Clinical Manager has already created an on-site file for each staff member, which includes copies of training plans & training records/certificates, and signed performance evaluations.
The Manager will review these records at the end of each quarter as a aid to encourage staff to schedule and complete trainings listed on their annual plans. In turn, the Manager will present a quarterly status report to the Regional Director.
The Manager will compare these records with HR every 6 months to ensure completeness of both files. This will assist the manager to maintain a more hands-on record of the type and number of training hours for each staff.
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on January 25, 2012 for the time period of January through December 2011. The exit route used was not listed on any of the fire drill log forms for all of the fire drills conducted in 2011. It could not be verified that alternate exit routes were utilized during the fire drills that took place from January through December 2011.
An interview with the clinical supervisor was conducted on January 25, 2012. It was confirmed that the exit route used was not documented on the fire drill log forms reviewed.
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Plan of Correction
Beginning February, 2012, the Clinical Manager (or designee) of each satellite facility, who will conduct the drill, will alternate emergency exits with each subsequent month's fire drill and will document which exit is utilized. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to accurately document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in four of five client records.
The findings include:
Six partial hospitalization client records were reviewed on January 9 & 25, 2012. Five of the six client records reviewed required documentation of an individual treatment and rehabilitation plan which included the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans in client records # 2, 4, 5 and 6 did not have accurate documentation of the type and frequency of treatment and rehabilitation services.
Client #2 was admitted to treatment on April 7, 2011 and discharged on June 6, 2011. The individual treatment and rehabilitation plan was developed on April 11, 2011. The type and frequency of treatment and rehabilitation services was documented as 1-2 individual sessions per week and group sessions 5 times per week. Clients in the partial hospitalization treatment activity are required to have at least 2 individual sessions per week.
Client #4 was admitted to treatment on January 11, 2012. The individual treatment and rehabilitation plan was developed on January 12, 2012. The type and frequency of treatment and rehabilitation services was documented as 1-2 individual sessions per week and group sessions 5 times per week. Clients in the partial hospitalization treatment activity are required to have at least 2 individual sessions per week.
Client #5 was admitted to treatment on December 28, 2011. The individual treatment and rehabilitation plan was developed on January 4, 2012. The type and frequency of treatment and rehabilitation services was documented as "YYAP PHP" 3 days per week. The frequency of individual and group sessions was not clear.
Client #6 was admitted to treatment on December 20, 2011. The individual treatment and rehabilitation plan was developed on December 21, 2011. The type and frequency of treatment and rehabilitation services was documented as 1-2 individual sessions per week and group sessions 5 times per week. Clients in the partial hospitalization treatment activity are required to have at least 2 individual sessions per week.
Interviews with the facility director and clinical supervisor took place on January 25, 2012. The aforementioned information was confirmed.
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Plan of Correction
Regarding treatment plans related to those patients enrolled in partial hospitalization, beginning immediately the treatment plans should and will specify that the patient will receive a minimum of 3 or a maximum of 5 group sessions/week and 2 individual sessions/week.
Related to this protcol, the assigned counselor and the clinical manager will ensure that each patient receives the prescribed frequency of each modality each week (when in attendance) and that the patient's medical record reflects documentation of all sessions conducted and/or the patient's absence.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to accurately document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of five client records.
The findings include:
Eight outpatient client records were reviewed on January 9 & 25, 2012. Five of the eight client records reviewed required documentation of an individual treatment and rehabilitation plan which included the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans in client records # 10, 11, 12, 13 and 14 did not have accurate documentation of the type and frequency of treatment and rehabilitation services.
Client #10 was admitted to treatment on February 14, 2011 and discharged on May 12, 2011. The individual treatment and rehabilitation plan was developed on February 15, 2011. The type and frequency of treatment and rehabilitation services was documented as 3 group sessions per week. There was no documentation of the frequency of individual sessions.
Client #11 was admitted to treatment on September 19, 2011. The individual treatment and rehabilitation plan was developed on September 22, 2011. The type and frequency of treatment and rehabilitation services was documented as IOP 3 days per week. There was no documentation of the type of sessions that were to be offered.
Client #12 was admitted to treatment on October 31, 2011. The individual treatment and rehabilitation plan was developed on November 2, 2011. The type and frequency of treatment and rehabilitation services was documented as 3 group sessions per week. There was no documentation of the frequency of individual sessions.
Client #13 was admitted to treatment on November 21, 2011. The individual treatment and rehabilitation plan was developed on November 21, 2011. The type and frequency of treatment and rehabilitation services was documented as 3 group sessions per week. There was no documentation of the frequency of individual sessions.
Client #14 was admitted to treatment on August 30, 2011. The individual treatment and rehabilitation plan was developed on September 13, 2011. The type and frequency of treatment and rehabilitation services was documented as individual sessions. There was no documentation of the frequency of individual sessions.
Interviews with the facility director and clinical supervisor took place on January 25, 2012. The aforementioned information was confirmed.
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Plan of Correction
Regarding treatment plans related to those patients enrolled in the intensive outpatient programs and outpatient groups, the treatment plans should and will specify that the patient will receive the specific number of prescribed group sessions per week or per month and 1 individual session/every 60 days (or 1/two months ).
Beginning immediately, the assigned counselor and the clinical manager will ensure that each patient receives the prescribed frequency of modality each (when in attendance) and that the patient's medical record reflects documentation of all sessions conducted and/or the patient's absence.
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