INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18 - 19, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 21, 2007.
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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 failed to document HIV/AIDS and tuberculosis training requirements for one of ten support staff within two years of employment. A review of the support staff page of the staffing requirements facility summary report documented the lack of the training requirement.
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Plan of Correction
TRAINING REQUIREMENTS WILL BE DISTRIBUTED TO ALL STAFF AND PROGRAM DIRECTOR WILL REVIEW TRAINING CALENDERS TO IDENTIFY TRAININGS NEEDED. STAFF WITHOUT HIV/AIDS AND TB TRAING WILL BE SIGNED UP FOR THE NEXT STATE APPROVED TRAINING OFFERED IN THE PITTSBURGH AREA. |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
The project failed to comply with 55 Pa. Code Part III. The project physician failed to review and sign-off the treatment plan updates as required by the Department of Public Welfare.
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Plan of Correction
ALL TREATMENT PLANS AND TREATMENT PLAN UPDATES OF PUBLICLY FUNDED PATIENTS WILL BE REVIEWED AND SIGNED BY A PHYSICIAN. PROGRAM DIRECTOR OR CLINICAL MANAGER WILL FOLLOW THE PROTOCOL GRC HAS USED FOR THE PHYSICIAN REVIEW OF INITIAL TREATMENT PLANS OF PUBLICALLY FUNDED CLIENTS. ALL PLANS WILL BE ROUTED TO THE CLERICAL ASST. AT GREENTREE SITE AND FORWARDED TO PHYSICIAN. EFFECTIVE IMMEDIATELY. |