Observations
Based on a review of staff records, the facility failed to ensure that staff persons received at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in one of two applicable records.
Staff #4 was hired as a Counselor on November 14, 2023 and is still in the position. The TB/STD training was due to be completed within the first year of employment, by November 14, 2024. Staff #4 ' s record did not contain documentation of a completed TB/STD training at time of review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
TAG L 0067
704.11 © (1) Mandatory Communicable Disease Training
1. The Facility Director has ultimate responsibility for the overall compliance for this plan of correction.
2. The DDAP subsequent findings were presented to Penn Highlands Mon Valley Senior Leadership team on Thursday July 24, 2025.
3. The following 704.11 Mandatory Communicable Disease Training education item has been addressed since the DDAP visit on July 14, 2025.
a. All counseling staff including staff member 4 have now received a minimum of 6 hours of HIV/AIDS and at least 4 hours of Tuberculosis, sexually transmitted disease and other health related topics training using the Division of Drug and Alcohol Program licensing alert from 6-97 approved curriculum. All counselors and counselor assist completed the training requirement effective August 4, 2025.
b. Attached are the Certificates of completion for the counselors /counselor assist that received and completed regulation requirement education.
c. Overall Completion Date: for education training for Staff # 4 was effective August 4, 2025.
d. The facility will conduct all required education trainings during orientation within the first 90 days of employment for all substance recovery unit new hires.
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