INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Northeast Treatment Centers, 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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that 1 employee received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #15 was hired as a counselor on 7/13/2016 and was due to have the communicable disease trainings no later than 7/13/17. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Program Director will coordinate a scheduled TB/STD training to be conducted where Employee #15 will attend. The TB/STD training was scheduled for and took place on 2/6/18. The Program Director will review and monitor personnel files quarterly to ensure all employees receive TB/STD training within one year of hire date to avoid future infractions regarding licensure standard 704.11. Employees will be enrolled in a TB/STD training accordingly to meet the training requirements for this standard. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of 8 client records, the facility failed to ensure that there was documentation of acknowledgment by the client that they were provided proper orientation to the project's programs in all 8 records reviewed.
Client #1 was admitted on 8/02/2017 and was still active as of the inspection.
Client #2 was admitted on 10/20/2017 and was still active as of the inspection.
Client #3 was admitted on 3/24/2017 and was still active as of the inspection.
Client #4 was admitted on 6/21/2017 and was still active as of the inspection.
Client #5 was admitted on 1/25/2017 and was discharged on 6/19/2017.
Client #6 was admitted on 3/01/2017 and was discharged on 10/16/2017.
Client #7 was admitted on 1/27/2017 and was discharged on 11/13/2017.
Client #8 was admitted on 1/25/2017 and was discharged on 12/26/2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients receive and sign-off on a client orientation to the program. This will be developed by the end of March 30, 2018 and distributed to all new participants enrolling in the IOP/OP program. Staff will ensure that participants provide a signature acknowledging receipt. Program Director will provide training to all staff who review the orientation process with new clients to ensure all are oriented to the program. Clients
who are currently enrolled will
review the client orientation with
their counselor and will also
complete this by end of March 30,
2018. |