INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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 and a plan of correction is due on February 29, 2008.
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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 the personnel training record, the facility failed to complete an individual training plan for employee record #1.
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Plan of Correction
- The President/CEO will complete an annual training plan for 2008 by February 25, 2008. The Vice President of Human Resources will review the plan and ensure that the training hours are completed as scheduled. |
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 the personnel training records, the facility failed to provide documentation of HIV/AIDS training in employee record #6 and TB/STD training in employee record #7.
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Plan of Correction
- HIV/AIDS and TB/STD trainings are included on the respective employees' annual training plans. - The Clinical Manager will ensure that these employees are scheduled for the trainings as soon as they become available. - The Regional Director will monitor this activity quarterly until the trainings have been completed. |
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 the personnel training records, the facility failed to provide documentation of the required 25 hour minimum for the 2007 training year. Refer to employee training records # 4 and 5.
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Plan of Correction
- To ensure closer monitoring of staff trainings, the Clinical Manager will create an on-site file for each staff member, which will include 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.
- These on-site files on all staff will be constructed by February 11, 2008 and will be maintained thereafter. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on client record reviews on 1-28-08, the facility failed to obtain an informed consent to release information from the client prior to the disclosure of information pertaining to that client. Refer to client records #4, 5, 6, 11, and 15.
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Plan of Correction
- On January 30, 2008, the Regional Director meet with the newest staff member who incorrectly completed the consent forms in question to provide explicit instructions on how to prepare the consent for release of information form, with special attention to the section - "the purpose of the consent". - On January 31, 2008, The Clinical Manager meet with all staff to review the procedures for completing consents to release information.
- At the time of each patient's admission, the Clinical Manager will review this newest's staff member's completed consent forms, during time frame February 1 through February 22, 2008, to ensure accurate preparation of the consent forms. Also, on an ongoing bases, during the intitial staffing of each case, the Clinical Manager will review all consents to ensure accuracy. |