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 25-26, 2024 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) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of administrative records, the facility failed to 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: An assessment of staff training needs; An overall plan for addressing these needs; A mechanism to collect feedback on completed training; An annual evaluation of the overall training plan.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A staff development program and policy have been created for agency personal including time frames for administration and review. Indicating who is responsible for completion of said responsibilities.
This process was immediately instituted and is currently occurring. Policy AM-06 was created and instituted. Awaiting CNO approval. |
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, the facility failed to ensure staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment in one of six records.
Staff #5 was hired as a counselor assistant on August 27, 2023 and still employed at time of inspection. Staff #5 was due to have the communicable disease trainings no later than August 27, 2024. Staff #5 did not complete TB/STD training until November 12, 2024, and did not complete HIV/AIDS training until November 15, 2024.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the November 21, 2023 licensing inspection.
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Plan of Correction
The facility has added the required 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health topics training into employee's formal system training. Time is specifically set aside within the first two months of employment for completion of this requirement.
This has been initiated immediately by the Facility director and will be a shared responsibility of the Program Director.
Utilizing a Department approved curriculum, the Facility Director, Program Director, and nursing education department will collaborate to create a training which meets the requirements of these trainings before June 1st, 2025. |