INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection KG816701 Self Help Movement, Inc was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this inspection and a plan of correction is required.
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Plan of Correction
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? 717.15(c) LICENSURE House Manager
§ 717.15. House Manager.
(c) The house manager shall complete at least 6 hours of training in one or more of the following areas within 6 months of becoming house manager, and annually thereafter:
(1) Fiscal policy.
(2) Administration.
(3) Program planning.
(4) Quality assurance.
(5) Program licensure.
(6) Personnel management.
(7) Confidentiality.
(8) Ethics.
(9) Trends in drug use and misuse.
(10) Developmental psychology.
(11) Interaction of addiction and mental illness.
(12) Cultural awareness.
(13) Sexual harassment.
(14) Relapse prevention.
(15) Substance use disorders.
(16) Peer support or mutual aid groups.
(17) Best practices for medication control and self-administration.
(18) Infection control.
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Observations
Based on a review of staff records, the recovery house failed to complete the required annual 6 hours training for the House Manager using a department approved curriculum training.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Human Resources Director
and/or designee will ensure that the House Manager receives the required renewal of his CPR certification by either sending him out for the required training at an approved site or setting the training up in-house as soon as possible.
The Human Resources Director and/or designee will monitor the RELIAS training system on a monthly basis for all employees to ensure that they are on track for completing their required trainings.
The House Manager completed his 6 hours of training on 12/9/24. |
§ 717.18(c)(1) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(1) Cardiopulmonary resuscitation (CPR) certification.
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Observations
Based on a review of staff records, the recovery house failed to complete House Manager training for CPR certification renewal for house manager using a department approved curriculum training.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Human Resources Director
and/or designee will ensure that the House Manager receives the required renewal of his CPR certification by either sending him out for the required training at an approved site or setting the training up in-house as soon as possible.
The Human Resources Director and/or designee will monitor the RELIAS training system on a monthly basis for all employees to ensure that they are on track for completing their required trainings.
The House Manager completed his CPR training on 11/20/24. |