INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16-18,2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance Medical Services 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 and a plan of correction is due on October 20, 2008.
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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 ten personnel/training records on 9-16-08, eight records were required to have the general training requirements. Of these eight records, the facility failed to document the training in one personnel record.Finding: The facility did not document the required TB/STD training attendance for personnel record #9. The training was due by November 2007.
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Plan of Correction
The facility did not document nor provide the required TB/STD training for all personnel that was to be completed by 11/2007. The Clinical Supervisor has scheduled the training for the identified staff. The Facility Director will obtain the necessary curriculum from the Department and oversee training of medical staff to provide authorized training to employees in the future. The Clinical Supervisor will be responsible to ensure that all staff are compliant with this regulation in the future and will maintain a training data base that will facilitate this process. These trainings will be documented in the employee training file. |