INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 02, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, Z8736701 Newfound Freedom was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing. 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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§ 717.18(c)(3) 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:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on a review of staff records, the recovery house failed to have staff complete the sexually transmitted diseases training using a department approved curriculum within the first 90 days of hire in all staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House manager will ensure all staff complete any missing required training within 90 days. All staff will review their individual training plan every 90 days to ensure all training is up to date. Owner/Director will ensure all staff training is completed with the staff approved timeline.
The missing training was completed on April 2nd, 2024. Moving forward, the Owner/Director will review all staff files every 90 days to ensure all records meet DDAP standards.
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