INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6, 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to ensure that the project director, who was hired on December 1, 2003, received an annual training plan for the current training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) The Project Director (PD)will adhere to state regulations that require the PD to have an annual training plan for the current training year.
2) The Vice President of Addiction Recovery Services will be responsible for
ensuring that the PD completes the annual training plan by January 7, 2019.
3)Annually, the Vice President of Addiction Recovery Services will ensure that the PD completes this for the
training year. |
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
The facility failed to ensure that 2 employees received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe, based on a review of the facility's Staffing Requirement Facility Report and the employee's personnel file.
Employee #10 was hired as a peer specialist on August 9, 2010.
Employee #11 was hired as a care manager on August 4, 2015.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
1) The Director of Quality Management shall find training dates for the staff members identified to come into compliance with the training requirements for 6 hours of HIV/AIDS training and 4 hours of TB/STD training.
2) The employees shall be assigned to the trainings and shall complete them as assigned.
3) Employee #10, hired on August 9, 2010 shall complete both HIV/AIDS and TB/STD training by 3/4/2019. This employee shall complete both trainings by March 4, 2019 (60 days from today's date).
4) Employee #11, hired on August 4, 2015 is currently out on maternity leave and is slated to return in approximately 12 weeks. She shall be assigned to complete the training within 60 days of her return from maternity leave.
4) Both employees were signed-up for HIV/AIDS training in December, but the state cancelled the trainings due to trainer availability. The Director of Quality Management shall be responsible for ensuring that the above mentioned individuals complete their HIV/AIDS and TB/STD training by the March 4, 2019 due date. |