INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clem- Mar House Inc. 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 five personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training within the regulatory timeframe.
Employee #5 was hired as a counselor assistant on January 5, 2022 and was due to have the communicable disease trainings no later than January 5, 2023. Employee #5 did not obtain the HIV/AIDS training until January 19, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clem-Mar House will follow guidelines in our policy and procedures manual to remain in compliance with chapter 704.
Our policy states the following: Training: During the hiring phase, the Project Director will review the employees/volunteers prior training and education experience.
Based on previous education, the Project Director, in conjunction with the House Manager, will develop a "individual training plan" as well as a "training needs assessment" for each staff member and volunteer. These will outline areas of needs and means of completion. Both will be completed upon hire and signed by the employee and their immediate supervisor or the Project Director. A new "individual training plan" and "training needs assessment" will be completed at the beginning of each new fiscal year, regardless of date of hire.
Counselors must complete the following trainings within their first year of employment:
HIV/AIDS Chapter 704.11
Tuberculosis (4)Chapter 704.11
Addictions 101
Confidentiality
Ethics
Case Management Series (Required for staff who did not complete the previous Case Management Overview curriculum).
The online Case Management Overview training must be completed before the Case Management Skills training.
(A) Case Management Overview ? https://www.train.org/pa/welcome
(B) Case Management Skills Training ? In-person or Virtual
Screening & Assessment; (Screening & Assessment is required only for case managers who perform screening and assessment.)
Motivational Interviewing, Advancing the Practice; (Required for staff hired on or after July 1, 2020; however, it is recommended that all complete training in Motivational Interviewing)
The ASAM Criteria, 2013
WITS Treatment Data System Training
The Facility Director and Clinical Team Led will monitor the completion of these trainings.
The Facility Director met with this individual to review training requirements and the expectation of completing trainings in a timely manner. This individual is in compliance with training requirements as of January 19, 2023.
Overall training requirements were reviewed during a staff meeting on April 5th, 2023 with all staff. The Facility Director will monitor the completion of trainings and compliance with Clem-Mar House Policy & Procedure of minimum of biannually. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of five personnel records, the facility failed to document the completion of 12 clock hours of annual training for one personnel reviewed.
Employee #1 was hired as a project director on November 1, 1994 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee # 1's record had no documented training hours.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clem-Mar House will follow guidelines in our policy and procedures manual to remain in compliance with chapter 704. Our policy states the following: Training: During the hiring phase, the Project Director will review the employees/volunteers prior training and education experience.
Based on previous education, the Project Director, in conjunction with the House Manager, will develop a "individual training plan" as well as a "training needs assessment" for each staff member and volunteer. These will outline areas of needs and means of completion. Both will be completed upon hire and signed by the employee and their immediate supervisor or the Project Director. A new "individual training plan" and "training needs assessment" will be completed at the beginning of each new fiscal year, regardless of date of hire.
The Project Director's Training Plain and Needs Assessment indicates that the Project Director is to complete 12 hours of training annually. This will be overseen by the Board of Directors as her immediate supervisor.
The Board of Directors will meet with the Project Director biannually to ensure the Project Director is in compliance with her training plan, including the completion of 12 training hours annually following The Clem-Mar House Policy and Procedure. This was reviewed with The Borad of Directors and Projector Director on April 5th, 2023. |