INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection and an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on February 9-10, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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.
|
Observations
The facility failed to ensure that staff received the mandatory training in one of one personnel record.
Employee # 10 was to complete the training by September 30, 2016. There was no documentation provided that the employee had completed the training.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The clinical supervisor is in charge of assuring that counselors complete the HIV/AIDS and STD/TB training requirements. The clinical supervisor will schedule a time for the physician assistant to provide the training of the core curriculum provided by DDAP for the completion of this staff training. Employee #10 will be scheduled for the training with the physician assistant and will complete the training by 4/15. To ensure future compliance the clinical supervisor will track clinician trainings quarterly and schedule the counselors for training to ensure completion of the HIV/AIDS, STD/ Hep C training requirements within one year as stated by regulatory guidelines. Project director will provide oversight to ensure compliance with this regulation. |