INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mill Creek Community Hospital 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 and a plan of correction is due on January 3, 2008.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
The hospital failed to employ a facility director who meets the educational requirements. Based on information obtained during the entrance conference and a review of the staffing requirements facility summary report completed on November 30, 2007 the facility director does not meet the educational requirements. The faculty director is a diploma nurse who does not hold the necessary Associates, Bachelor or graduate degree in a related field.
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Plan of Correction
The position of project/facility director will be held by the President/CEO of Millcreek Community Hospital who meets the educational requirements as stated in the regulation. The Director of Patient Care Services will hold the position of supervisor for the drug and alcohol unit. |
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The hospital failed to meet the staff development program related to the feedback on related training. Two of two staff development files reviewed on November 30, 2007 did not include a feedback mechanism on completed training. An interview with the facility director on November 30, 2007 verified the lack of training feed back information in the staff development files.
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Plan of Correction
The project/facility director or designee will develop a Training Feedback form to be completed by the drug and alcohol staff after each training session. This form will be developed within the next 30 days. The completed forms will be placed in the employees file. |
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
The hospital failed to establish written individual training plans for employees. Two of two personnel files reviewed on November 30, 2007 failed to provide documentation of individual training plans. An interview with the facility director, coordinator of quality assurance and a hospital consultant on November 30, 2007 indicated individual training plans are established for recently hired staff only and are not completed on a annual basis for each employee.
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Plan of Correction
The project/facility director or designee will develop individual training plans for each employee in the drug and alcohol unit. These plans will be completed within the next 30 days. The training plan will include in-house as well as training an employee might receive outside the facility. The training plans will be made available to the employee as well as placed in the employees file. |
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 hospital failed to meet the staff development requirements related to HIV/AIDS training. Based on information acquired during the entrance conference on November 30, 2007 and a review of the staffing requirements summary report completed on November 30, 2007, counselors have not received the minimum of 6 hours of HIV/AIDS training within the first year of employment. Other non clinical staff have not completed the required training within the first 2 years of employment.
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Plan of Correction
The project/facility director or designee will ensure that counselors receive a minimum of 6 hours of HIV/AIDS training within the first year of employment. The facility will ensure that non-clinical staff receive at a minimum 6 hours of HIV/AIDS training within the first 2 years of employment.
The clinical educator of Millcreek Community Hospital will develop an educational program for HIV/AIDS that meets the requirements set forth by the Department of Health. This program will at a minimun be 6 hours in length. Millcreek Community Hospital will use the approved curriculum as set forth in the Licensing Alert 1-97 to develop the program. This educational program will be developed within the next 90 days. Millcreek Community Hospital will also utilize outside approved educational resources to meet the needs of the employees as they are made available. All drug and alcohol employees will receive the HIV/AIDS training within the 2008 year. |