INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on May 1, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Recovery Center of America at Devon was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiency was identified during this inspection:
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Plan of Correction
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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 the facility's Staffing Requirement Facility Summary Report and a conversation with facility staff, the facility failed to ensure that all staff completed the mandatory minimum of 6 hours of HIV/AIDS training within the regulatory time frame.
Employee # 29 was hired as a counselor on November 5, 2018 training was due no later than November 5, 2019. Training was not completed at the time of inspection.
Employee # 30 was hired as a driver on December 4, 2017 and the HIV/AIDS training was due no later than December 4, 2019. The training was not completed at the time of the inspection.
Employee # 31 was hired as a spiritual advisor on June 5, 2017 and the HIV/AIDS training was due no later than June 5, 2019. The training was not completed at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
On 5/12/20, Devon's Training Manager received approval from DDAP to develop HIV/AIDS training which meets DDAP requirements per licensing alert. Staff named in citation will be trained on 6/5/20. As of 5/10/20, ongoing monitoring will be conducted by our Training Department and Human Resources Department. The Training Department will provide a list of staff who need to attend a DDAP training to Leadership members. Human Resources and Executive Director will work with Leadership and staff to support attendance through online registration. Staff members scheduled for DDAP trainings will be placed on the work schedule to accommodate the training date to ensure compliance and attendance. CEO will re-educate Leadership members on 5/27/20 informing Leadership of the new process and expectations. Leadership will be required to sign a sign-in sheet. Findings from staff trainings will be reported to Human Resources, Executive Director, CEO. Staff will face disciplinary action should they not attend a training as scheduled.
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