INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, TrueNorth Wellness Services 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of five staff training records on October 1, 2021, the facility failed to ensure there was a mechanism to collect feedback on completed training in all five records reviewed.
No trainings for the past training year had a mechanism to collect feedback regarding documented trainings.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
9/28/2021 Facility Director told Clinical Supervisor to remind all staff to complete the form we have for evaluation of training each time they submit a training certificate to us. On 9/30/2021 Clinical Supervisor reminded all staff at the weekly staff meeting to complete the evaluation of training form for each training they attend. A blank copy of the form was given to each staff. Clinical Supervisor will review certificates of training turned in by staff weekly and obtain completed form from staff. Facility Director will inform Clinical Supervisor in the event a staff does not include this form when staff give certificates to Director. Clinical Supervisor will follow up with all staff if this occurs. Clinical Supervisor will review during weekly staff meetings and inform staff to turn in any missing certificates along with the evaluation form. Clinical Supervisor has created individual development plans to address all areas that we received citations for. Clinical Supervisor will review these plans with staff every 90 days and further disciplinary action will be taken as needed. |
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 six staff records conducted during the inspection on October 1, 2021, the facility failed to ensure that two staff had the mandatory training in communicable diseases within the required time frames.
Staff #5 was hired as a counselor on August 13, 2018. The staff person was required to have 4 hours of TB/STD training by August 13, 2019, but at the time of the inspection, the staff person had no documentation of training in this area.
Staff #6 was hired as a receptionist on February 2, 2019. The staff person was required to have 4 hours of TB/STD training by February 2, 2021, but at the time of the inspection, the staff person had no documentation of training in this area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 9/30/2021 Clinical Supervisor reminded Staff # 5 and Staff #6 to sign up for the required HIV/AIDS and TB/STD trainings as soon as available. Facility is adding the Relias Training System to ensure that all staff have access to required trainings when the trainings are not available elsewhere. Clinical Supervisor will monitor all staff's trainings and ensure they are completed within the required time frame. Facility Director will meet with Clinical Supervisor for supervision and review progress on staff training. Clinical Supervisor has created individual development plans to address all areas that we received citations for. Clinical Supervisor will review these plans with staff every 90 days and further disciplinary action will be taken as needed. |