INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone/buprenorphine monitoring inspection conducted on November 20 - 21, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC McKeesport Hospital 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)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of administrative information, the facility failed to document an assessment of staff training needs for the January - December 2023 training year.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. UPMC McKeesport Addiction Medicine Program Manager will immediately implement documentation of an assessment of staff training needs under 704.11 staff development program.
2. The program manager will be responsible for implementation and monitoring of staff training needs assessments for all staff. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of administrative information, the facility failed to document an overall plan for addressing staff training needs for the January - December 2023 training year.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. UPMC McKeesport Addiction Medicine Program Manager will immediately implement documentation of an overall plan addressing staff training needs under 704.11 staff development program.
2. The program manager will be responsible for implementation and monitoring of staff training needs assessments for all staff. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative information, the facility failed to document an annual evaluation of the overall training plan for the January - December 2022 training year.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. UPMC McKeesport Addiction Medicine Program Manager will immediately implement documentation of an annual evaluation of the overall training plan under 704.11 staff development program.
2. The program manager will be responsible for implementation and monitoring of staff training needs assessments for all staff. |
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 training records, the facility failed to document an annual written individual training plan for each employee, appropriate to that employee's skill level and with input from both the employee and the supervisor in seven of ten records.
Employee # 1 was hired at the facility on May 15, 2016 and was hired for the current position on June 1, 2021.
Employee # 2 was hired at the facility on October 7, 2019 and was hired for the current position on October 23, 2022.
Employee # 3 was hired at the facility on December 10, 2018.
Employee # 4 was hired at the facility on June 6, 2022.
Employee # 8 was hired at the facility on December 5, 2021 and was hired for the current position on August 27, 2023.
Employee # 9 was hired at the facility on June 8, 2022.
Employee # 10 was hired at the facility on May 17, 2021.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. UPMC McKeesport Addiction Medicine Program Manager will implement a written individual training plan for each employee, appropriate to that employee's skill level that is developed annually with input from both staff and supervisor according to guidance under 704.11.
2. The program manager will be responsible for implementation and monitoring of ongoing individual training plans for all current and future staff. Program manager will meet with each employee annually to complete that year's plan accordingly.
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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 training records and the facility ' s Staffing Requirements Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training in two of three applicable records.
Employee # 8 was hired at the facility on December 5, 2021 and was hired for the current position on August 27, 2023. The TB/STD training was due to be completed by December 5, 2022 and was not completed at the time of the inspection.
Employee # 9 was hired at the facility on June 8, 2022 and was due to have HIV/AIDS training and TB/STD training no later than June 8, 2023. HIV/AIDS training and TB/STD training was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. The program manager will be responsible for monitoring that all current and future staff attain required trainings within the regulatory timeframe under 704.11.
Employee #8 is scheduled to complete DDAP TB/STD training on 2/9/2024.
Employee #9 will complete 6 hours of HIV/AIDS training immediately through change.org DDAP approved module and is scheduled to complete DDAP TB/STD training on 2/9/2024. |