INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Central Behavioral Health, 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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #1 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 #1 was hired as the project director on 11/30/14 and was due to have the communicable disease trainings no later than 11/30/16. There is no documentation in the personnel file of the completion of the required 4 hours of TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program director has identified an available training that meets the TB/STD training requirements and has enrolled in the course. It is offered by Gaudenzia and will take place on October 10th, 2017.
Facility director will review each staff member's training needs on a monthly basis in order to ensure that requirements are met. |