INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wyoming Valley Alcohol and Drug 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(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 Staffing Requirements Facility Summary Report (SRFSR) and discussion with the facility director, the facility failed to ensure that staff persons 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 Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment.
Employee #9 was hired as a counselor assistant on March 1, 2023 and was still in the position at the time of the inspection. There was no documentation that the TB/STD training had been completed in the personnel record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
This has been addressed in several ways. A staff meeting was held to remind all employees about the necessary trainings that need to be completed in a period of specified time. In addition, this will be discussed with employees during their supervision meetings which are held consistently. Training manuals will be reviewed at least once monthly by the Clinical Supervisor to ensure compliance. The training missing by the employee mentioned will be scheduled ASAP to suffice the requirement. |