INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CleanSlate Medical Group of Pennsylvania, LLC - Scranton North was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiency 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 five 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 4 hours of TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 3 was hired as a medical assistant on December 12, 2022 and was due to have the communicable disease trainings no later than December 12, 2024. However, there was no documentation of the completion of the TB/STD or HIV/AIDS trainings as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 23, 2024 annual licensing inspection.
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Plan of Correction
All current PA employees will be trained on the following Communicable Diseases of HIV/AIDS and TB/STD through DDAP directly.
The locations Center Manager will be responsible for ensuring all staff receive the required training by end of Q3 9/30/2025.
All new employees will be trained within their 1st or 2nd year of employment via DDAP directly. The locations Center Manager will be responsible for tracking completing of these trainings in the required timeframe. 6-month audits on required trainings will be conducted by the Learning and Development team. |