INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13- 16, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment, Inc. 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(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records and discussions with the facility director, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of one personnel record.
The findings include:
Personnel records were reviewed on August 13, 2012 and discussions with the facility director occurred throughout the August 13-16, 2012 survey. One personnel record reviewed was that of the newest clinical supervisor. The documentation of monthly meetings between the clinical supervisor and his/her supervisor for the first six months of employment in that position was not available. The facility failed to document monthly supervision meetings in personnel record # 7.
Employee # 7 was hired as a clinical supervisor on December 5, 2011. Monthly supervision meetings were required to take place in January, February, March, April, May and June 2012. There was no documentation of monthly supervision meetings for employee # 7.
The findings were reviewed with the project director and facility director and were not disputed.
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Plan of Correction
Renewal Treatment Inc. Program Directors (Facility Director) shall document monthly meetings with all new hire Clinical Supervisors during their first six (6) months of employment. The Program Director shall maintain this documentation in a file intended for this purpose. The Program Director will meet monthly with Employee #7; for supervision meetings, with the purpose of discussing their duties and performance. This will take place during the next six (6) months and shall be subsequently documented. This requirement shall take place for all future new hire Clinical Supervisors. The Project Director and Program Director shall ensure compliance with this POC. This POC is currently in place. |
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 provide documentation of HIV/AIDS and TB/STD training in two out of seven records reviewed.
The findings include:
Ten personnel records were reviewed on August 13, 2012. Seven of the ten staff members were required to have documentation of six hours of HIV/AIDS training and a minimum of four hours of TB/STD and other Communicable Diseases training. Counselors shall complete the training within the first year of employment. Two of the records did not have the required documentation.
Employee #12 was hired as a counselor on 6/20/11. Four hours of TB/STD training was required to be completed by 6/20/2012. Employee #12 failed to obtain the training as August 13, 2012.
Employee #13 was hired as a counselor on 8/5/11. Six hours of HIV/AIDS training was required to be completed by 8/5/12. Employee #13 failed to obtain the training as of August 13, 2012.
The findings were reviewed with the project director and the facility director and were not disputed.
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Plan of Correction
Renewal Treatment Inc. staff shall adhere to all training regulations including the requirement for Counselors to obtain HIV/AIDS (6 hours) and TB/STD (4 hours) training within their first year of employment. Clinical Supervisors will complete a training plan with each new Counselor during their first month of employment which will contain this requirement. Clinical Supervisors will provide follow-up to ensure that new Counselors are scheduled for these trainings within their first year of employment and that documentation of completion is received. Documentation of completion shall be kept in each employee's training file. Clinical Supervisors shall review their staff's training records on a regular basis to ensure continued compliance and discuss this requirement during supervision meetings. The Program Director and Clinical Supervisors shall ensure continued compliance with this POA. This POA is in place. |