INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on July 20, 2015, by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Al-Assist Behavioral Health Care Center, 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 supervisory review:
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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 the Staffing Requirements Facility Summary Report, the facility failed to provide documentation of TB/STD training for one of the clinical staff requiring the training within the first year of employment.The findings include:Employee was hired on 2/18/14 as a Counselor III and was required to obtain 4 hours of TB/STD training by 2/18/15. The employee failed to obtain the training as of the date of the inspection.
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Plan of Correction
Standard in Noncompliance
704.11(c)(1) Mandatory Communicable Disease training
In effort to comply with regulation 704.11(c)(1)
The regulation standard has been reviewed, agency processes has been reviewed and reinforced. As part of the staff development program all supervisors will ensure that all newly hired individuals written training plan include scheduling within the required timeframe 4 training hours of tuberculosis and sexually transmitted diseases along with other required trainings to be completed within the first year of hire. Training will be scheduled based on BHTEN's training schedule. If trainings are not offered within the allotted timeframe through BHTEN training will be sought after through accredited medical training facilities. In addition, the written training plan will be submitted to Facility Director for review no later than 15 days after hire date. Any revisions will be submitted within 5 days of submission. The final written training plan will be completed within the first 30 days of employment. The Clinical Coordinator will monitor the completion of these trainings during supervision sessions. Upon completion of these trainings a copy of the certificates will be sent to the credentialing department to be placed in employee's file.
As for employee out of compliance STD/TB raining will be completed within the next 90 days through BHTEN or a credentialed/ certified medical trainer.
Correction time: March 25, 2016
On-going Monitoring of compliance with this standard will be conducted by the Quality Assurance Department monthly. |