INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on March 11, 2020. Based on the findings of the on-site inspection, Outside In Pathway to Recovery Outpatient Services was found to not 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of eight personnel records reviewed on March 11, 2020, the project failed to ensure that the project director completed at least 12 clock hours of training annually. The project director had 6.5 hours of training completed for the training year July 1, 2018 through June 30, 2019. These findings were reviewed with the project during the licensing process.
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Plan of Correction
The facility director will remind the project director of the requirement to complete at least 12 clock hours of training annually by 3/31/2020. The project director will complete at least 12 hours of training in the training period July 1, 2019 through June 30, 2020. The project director will complete at least 12 hours of training in each training year. The HR Manager will ensure that the 12 hours of training are complete. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The project failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights to include non-discrimination in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. The project's bill of rights was missing marital status. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The facility director will request that marital status be added to the project's bill of rights as of 3/31/2020. The project's administrative assistant will make the addition of marital status to the bill of rights as of 3/31/2020 on the electronic health record KIPU. The facility director will ensure that this change was made on 3/31/2020. |