INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 3, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Gettysburg Psychiatric 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 nine personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that one employee received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee #3 was hired as a counselor on July 15, 2019 and was due to have the communicable disease trainings no later than July 15, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Employee #3 completed HIV/Aids training through a previous employer. Employee #3 has been trying to obtain a copy of the training certificate. The training was completed on 1/12/2017 and a copy of the certificate is now in the employee's PCS training file.
The Director of Outpatient Services is currently working with the PCS Training Department to develop curriculum to be approved by DDAP so that in-house communicable disease trainings can be offered to PCS staff to ensure completion within the regulatory timeframes. |