INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 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, Independent Family Services, 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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704.11(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 one employee received the minimum of at least 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment in one of two records.
Employee #3 was hired as a counselor on March 18, 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 March 18, 2023. No documentation was provided that staff #3 had completed at least 6 hours of HIV/AIDS and at least 4 hours of 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
On 11/29/23 IFS employee #3 completed the PA DDAP 6-hour training: "HIV for Substance Use Disorder Professionals". The certificate of completion was sent via email to the DDAP licensure specialist.
On 12/6/23 IFS employee #3 received registration confirmation from RA-DATrainings@pa.gov website for the 4 hour TB/STD/Hepatitis training. Once completed this will meet all HIV/TB/STD/Hepatitis training requirements as per policy 704.11 of the PA DDAP regulations.
Upon hire, all general training requirements as per policy 704.11(c)(1-4) will be reviewed by the IFS Program Director and new hire when completing the initial IFS SUD Individual Training Plan for the new employee and necessary training needs will be monitored and documented. The IFS Compliance Department will track and verify adherence to all PA DDAP staffing regulations. |