INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Graniteville House of Recovery 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(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 four applicable personnel records, the facility failed to develop written individual training plans for each employee, appropriate to that employee ' s skill level, that were developed annually with input from both the employee and the supervisor in all records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Existing annual training plans will be updated by 9/21 to reflect the employee's skill level and development goals with acknowledged input from both employee and supervisor. Future annual training plans will reflect interest/goals/skills of the employee with acknowledged input from both employee and supervisor. Ongoing responsibility of Facility Director. |
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 six personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's one employee received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #4 was hired as a counselor on April 15, 2021 and was due to have the communicable disease trainings no later than April 15, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee was registered for TB training 10/31/22 and will attempt registration for November 2022 HIV training offerings (registration not open until October 2022). Facility Director will monitor training plans throughout the year to ensure ongoing compliance and to make relevant employees aware of training availability. Ongoing responsibility of Facility Director |