INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Outside In Pathway to Recovery Outpatient Services 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of employee personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level, and developed annually with input from both the employee and the supervisor for employee # 1.
Employee # 1 was hired as the project director/facility director on May 6, 2021 and was still in this position at the time of the inspection. Employee # 1 did not have a training plan documented in the employee record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Chief Operations Officer and the Project Director will meet and establish a training plan for the Project Director by April 29, 2023. The Human Resources Manager will ensure that a completed training plan is submitted with the Project Director's annual performance evaluation by the annual due date. |
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 records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee # 3 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on February 2, 2022 and was still in this position at the time of the inspection. Employee # 3 was due to have the communicable disease trainings no later than February 2, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Human Resources Manager has been instructed by Project Director to schedule the 6 hour HIV/AIDS training and the 4 hours of TB/STD and other health related topics as soon as possible. Employees who need to participate in this training will be required to attend on the scheduled date. It is anticipated that the training will be conducted on or before June 30, 2023. The Human Resources Manager will be responsible for scheduling both trainings on an annual basis as of April 20, 2023. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee # 5 was hired as a counselor on April 25, 2022 and was still in this position at the time of the inspection. There was no documentation of training to perform assigned tasks during an emergency in the employee record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Manager will ensure that each staff hired to work in the project will be trained to perform assigned tasks during an emergency, in addition to fires specifically, on their date of hire. Any staff member who does not currently have training to perform assigned tasks during an emergency will complete the training by April 28, 2023. The Project Director will request confirmation of this training on May 1, 2023. |