INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18 - 19, 2008, January 5 - 8, 2009, and January 20, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Squirrel Hill 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 and a plan of correction is due on February 27, 2009.
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Plan of Correction
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709.83(a)(11) LICENSURE Client records
709.83. 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 the review of client records, the facility failed to document follow up in one of one client record.
The findings include:
Eleven client records were reviewed on January 8 and January 20, 2009. Four partial hospitalization client records were reviewed. Follow up was required in one client record. The facility did not document follow up in client record # 1.
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Plan of Correction
- The Directors of all Gateway Rehab treatment programs will work with the VP of Treatment Programs and the Director of Research to redevelop policies and procedures for conducting and documenting follow-up contacts with patients, consistent with the regulatory standards. (Developed by April, 2009 and implemented by May, 2009) |
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 the review of client records, the facility failed to document follow up in one of one client record.
The findings include:
Eleven client records were reviewed on January 8 and January 20, 2009. Seven outpatient client records were reviewed. Follow up was required in one client record. The facility did not document follow up in client record # 5.
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Plan of Correction
- The Directors of all Gateway Rehab treatment programs will work with the VP of Treatment Programs and the Director of Research to redevelop policies and procedures for conducting and documenting follow-up contacts with patients, consistent with the regulatory standards. (Developed by April, 2009 and implemented by May, 2009) |
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 the review of personnel records, the facility failed to document HIV/AIDS and STD/TB training in four of eight personnel records.
The findings include:
Ten employee records were reviewed on December 18 - 19, 2008 and January 5, 2009. HIV/AIDS and STD/TB training was required in eight employee records. The facility failed to document HIV/AIDS training in employee records # 8, 9 and 10. The facility failed to document STD/TB training in employee records # 5, 8 and 9.
Employee # 5 is clinical staff and was hired on January 2, 2008. STD/TB training was due to be completed by January 2, 2009.
Employee # 8 is clinical staff and was hired on July 14, 2004. HIV/AIDS and STD/TB training was due to be completed by July 14, 2005.
Employee # 9 is support staff and was hired on April 26, 2005. HIV/AIDS and STD/TB training was due to be completed by April 26, 2007.
Employee # 10 is support staff and was hired on August 9, 2004. HIV/AIDS training was due to be completed by August 9, 2006.
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Plan of Correction
- The Regional Director and Clinical Manager have completed this year's staff training plans. HIV/AIDS and TB/STD trainings have been included on the respective employees' annual training plans.
- These staff members will be scheduled to attend the necessary trainings by the end of the second quarter of this year.
- To ensure closer monitoring of staff trainings, the Clinical Manager will create an on-site file for each staff member, including all support staff, which will include copies of training plans & training records/certificates.
- The Manager will review these records at the end of each quarter as an aid to assist staff in scheduling and completing the trainings listed on their annual plans, including required/mandatory trainings. 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 needed trainings for each staff.
- These on-site files on all staff will be updated and/or constructed by February 2, 2009 and will be maintained by the Clinical Manager thereafter.
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