INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 23, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services, LLC 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 personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employee's #6 and 7 received the 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.
Employee #6 was hired as a counselor on March 16, 2021 and was due to have the communicable disease trainings no later than March 16, 2022. There was no documentation in the personnel file of the completion of TB/STD training as of the date of the inspection.
Employee #7 was hired as a counselor on January 12, 2021 and was due to have the communicable disease trainings no later than January 12, 2022. There was no documentation in the personnel file of either communicable disease trainings as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director will develop and implement a training protocol for new staff using the DDAP Approved Curriculum for HIV Training and TB/STD Training to be provided on-site by our Medical Personnel which will meet the communicable disease training requirements as required by regulation. Facility Director will monitor through random employee training record audits. Documentation of the training protocol will be maintained on site for review by the state as needed and will be completed by 7/31/2022. |