INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 6-7, 2012 licensure renewal inspection. The follow-up inspection was conducted on June 18-19, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Pennsylvania Associates, LLC d/b/a Mount Pocono Medical, 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel and training records, the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision approved by the Department.
The findings include:
One personnel record for the position of Lead Counselor/Clinical Supervisor was reviewed on June 18, 2013. The facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services completed a core curriculum in clinical supervision approved by the Department in one of one record reviewed, personnel record #1.
Employee #1 was hired on November 11, 2011. The job description was signed for clinical supervisor. As of the date of the inspection the records failed to contain documentation that the employee had a minimum of two years experience in the provision of clinical supervision or that the employee had completed a core curriculum training in clinical supervision.
The findings were reviewed with the facility director and quality improvement staff member and was not disputed.
This is a repeat citation from the licensing inspection conducted on November 6-7, 2013.
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Plan of Correction
The new Facility Director has reviewed the standard 704.6(c)and the facility director will review the qualifications of staff being considered for promotion to the position of clinical supervisor and will ensure that they meet the qualifications prior to their being promoted and will ensure that when a new clinical supervisor is hired from outside, they will have verification that he/she has functioned in a clinical supervision capacity for a minimum period of 2 documented years. If the candidate does not meet the above standard, they will be required to complete the core curriculum in clinical supervision that is offered or preapproved by DDAP at the earliest available training session or if alternate coursework is used, that it be preapproved by DDAP prior to enrollment and completion. The training requirement will be added to the candidate's individual training plan.
The former Facility Director misunderstood the regulations and, due to a scheduling conflict with the DDAP training, allowed the lead counselor to enroll in alternate courses that did not have prior approval. This failed to meet the standard.
This new plan is effective immediately having been implemented this date 8/15/2013. The facility director and Director of Quality management will monitor the DDAP website and will enroll the lead counselor in the next available training. Plan will be completed by December 31, 2013, upon completion of the next available training approved by DDAP (December 2013 workshop). |
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 and training records, the facility failed to ensure that staff and volunteers received a minimum of 6 hours HIV/AIDS and at lest 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in accordance with the regulation.
The findings include:
One personnel record requiring documentation of the mandatory HIV/AIDS and TB/STD training was reviewed on June 18, 2013. The facility failed to document that employee # 2 received 6 hours HIV/AIDS and at lest 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum training in one of one record reviewed.
Employee # 2, a counselor, was hired on October 24, 2011. As of the date of the inspection, June 18, 2013, there was no documentation of the completion of 6 hours HIV/AIDS or 4 hours of TB/STD training using the Department approved curriculum.
The findings were reviewed with the facility director and quality improvement staff member.
This is a repeat citation from the licensing inspection conducted on November 6-7, 2013.
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Plan of Correction
Staff member completed department approved training on June 21, 2013. Training plans will be reviewed annually with the employees and lead counselor to ensure trainings are up to date. |