INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2022 through September 13, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mirmont Alcohol Rehabilitation Center d/b/a Mirmont Treatment Center., 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(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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure that all staff persons received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory time frame in one of eight applicable personnel records reviewed.
Employee #7 was hired as a counselor on August 23, 2021. The HIV/AIDS and TB/STD trainings were due no later than August 23. 2022. However, both of the trainings were 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
Departmental supervisors are responsible to assign mandatory training to newly hired staff within specified timeframes. HIV/AIDS and tuberculosis/STD training will be completed within 1 year for counselors/counselor assistants and within 2 years for non-clinical staff. Department supervisors will ensure compliance by scheduling staff for the training provided onsite which is scheduled in advance, twice per year for each training. Supervisors will collect certificates of completion and provide to Quality Manager(or designee) who maintains a list of due dates for mandatory trainings for all staff members. Training date reminders will be sent to staff and supervisors 2 weeks prior to training and confirmation for planned attendance will be communicated by supervisor. Plan of correction and process reviewed at Leadership meeting 9/21/2022. Employee #7 will be in compliance 10/28/2022. |