INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 2-3, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, George Junior Republic 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:
|
Plan of Correction
|
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.
|
Observations
The facility failed to ensure that staff received a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in three of three personnel records reviewed.
Nine personnel records were reviewed on March 2-3, 2020. Three required completion of the mandatory training.
Employee # 6 was hired as a counselor on September 9, 2018. STD/TB training was to be completed by September 9, 2019. There was no documentation the training had been completed.
Employees # 8 and 9 were both hired as night security on November 6, 2017. HIV/AIDS and STD/TB training was to be completed by November 6, 2019. There was no documentation the training had been completed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Facility Director will schedule training for employees #8 and #9 to complete a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics to be completed by May 1, 2020. The Facility Director will schedule training for employee #6 to complete a minimum of 4 hours of SDT/TB training by May 1, 2020. Documentation of the completed training will be included in the training file for each employee. The Facility Director will monitor training for all project employees to ensure that each employee complies with training standards mandated by the PA Department of Drug and Alcohol Programs for HIV/AIDS and tuberculosis, sexually transmitted diseases and other health related topics. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
The facility failed to document that the clients were informed of the right that no client may be deprived of a civil right solely by reason of treatment.
Seven client records were reviewed on March 2-3, 2020. All seven required documentation that the client was informed of the right.
Client records # 1, 2, 3, 4, 5, 6 and 7 did not document that the client was informed of this right.
These findings were reviewed with facility staff during the licensing inspection
|
Plan of Correction
The Facility Director will amend the procedures on client rights within the orientation packet to include the following: "A client receiving care or treatment under section 7 of the act ( 71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment" The Facility Director will obtain written acknowledgement of the amended procedures on client rights by all current clients and all future client which will be included in the client file. |