INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of the personnel and training records, the facility failed to document that a core curriculum in clinical supervision, provided by the Department, was completed in one of one record.
The findings include:
Eight personnel and training records were reviewed on August 31 - September 1 and September 15, 2015. One record was reviewed for the completion of a core curriculum in clinical supervision that was provided by the Department.
Employee #3 was hired as a counselor on April 3, 2013 and promoted to a supervisor on August 26, 2014. No documentation was available to show the employee functioned for 2 years as a supervisor in the provision of clinical services. The employee completed a clinical supervisory training that was not provided by the Department. There was no documentation that the training had been approved by the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and HR department will continue to monitor the DDAP training website for the Clinical Supervisor training, when available Clinical Supervisor will be registered as soon as possible. |
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 the review of personnel records, the facility failed to ensure that staff persons received 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 in one of one personnel record.
The findings include:
Twelve personnel records were reviewed on August 31 and September 1, 2015. One personnel record was reviewed for the completion of the HIV/AIDS and STD/TB training. There was no documentation of the training in personnel record # 5.
Employee # 5 was hired as a counselor on August 18, 2014. The HIV/AIDS and STD/TB training were to be completed by August 18, 2015. There was no documentation that the training had been completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #5 did attend a required training on 10/13/2015, that he was not in compliance for.
To ensure training compliance for all staff and their specific positions, bi-weekly checks on the training's will be done by Program Director and Human Resources department to register staff for needed training's as soon as possible. Additionally, as a part of orientation staff will register for all required training's that are available. After initial orientation then bi-weekly training checks will be done to ensure all employees are completing required training's within the required time-frame for their specific position. |