INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Warren General Hospital 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 July 28, 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
The project director failed to acquire a minimum of six hours of HIV/Aids and four hours of tuberculosis, sexually transmitted diseases within two years of employment.
Findings:
Based on a review of the staffing requirements facility summary report completed on July 2, 2008, a review of hospital training files and an interview with the facility director on July 2, 2008 at 11:45, the project director , hired on July 1, 2001, failed to acquire six hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within two years of employment. There was no verification of the required training , which was due on July 1, 2003, as of July 2, 2008.
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Plan of Correction
The Project Director will ensure that all employees comply with the education requirements set forth in 28 Pa. Code 704.11(c)(1). The Project Director completed the 4-hour TB/STD training on July 23, 2008, and is scheduled to complete the 6-hour HIV training on October 13, 2008. Thus, the facility anticipates full compliance with this standard by October 13, 2008. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
The project director failed to meet the twelve hour annual training requirement.
Findings:
Based on a review of the staffing requirements facility summary report completed on July 2, 2008, a review of hospital training files and an interview with the facility director on July 2, 2008 at 11:45, the project director , hired on July 1, 2001, failed to acquire twelve hours of training for the July 1, 2007 through June 30, 2008 training year. Six hours of training for the July 1, 2007 through June 30, 2008 were documented in the project director's training file.
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Plan of Correction
The Project Director will ensure that all employees comply with the education requirements set forth in 28 Pa. Code 704.11(d). The Project Director will complete 12 hours of continuing education by October 31, 2008. Education for this year will include 4 hours of TB/STD training, 6 hours of HIV training, and 2 hours of project-related education. |