INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 18, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia West Shore 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 facility records submitted during the presubmission process and the onsite inspection, the facility failed to ensure that all staff persons received the required training in communicable diseases.
Staff Person #6 was hired as a counselor assistant on 01/25/2016 and was promoted to a counselor on 05/23/2016. At the time of the onsite inspection there was no documentation that the staff person had not received the required 6 hours of HIV/AIDS training.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The employee #6 will register for the next available HIV/AIDS training.
The Program Supervisor will review specific core trainings that are needed within the first year of employment, including but not limited to HIV/AIDS, TB/STD. This will be done on a quarterly basis, at a minimium. Scheduling of trainings will be the responsibility of each employee and monitored by the Program Supervisor. Training reports are completed by the Administrative Manager on a monthly basis. The Program Director will monitor, through compliance training reports and staff meeting minutes. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on a review of facility records conducted during the onsite inspection, the facility failed to acquire Consent to Treatment forms signed by the client during the intake process in 5 of 5 records reviewed.
Client #8 had an intake performed on March 16, 2017.
Client #9 had an intake performed on April 11, 2017.
Client #10 had an intake performed on March 30, 2017.
Client #11 had an intake performed on April 14, 2017.
Client #12 had an intake performed on April 19, 2017.
These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
Effective immediately, all evaluation packets will include a Consent to Treatment form that will be reviewed and signed by the client on the day of the evaluation.
The Program Supervisor will advise clinical staff during the next staff meeting on 6/16/17 that they need to ensure compliance with the Consent to Treatment Forms.
The Administrative Manager and Program Supervisor will ensure the evaluation packets include all the necessary forms on a regular basis.
The Program Supervisor will monitor evaluation packets for compliance on a monthly basis.
The Program Director will maintain oversight for compliance. |