INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 6, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resources for Human Development Inc. Morris House 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(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
Based on a review of the Staffing Requirements Facility Summary Report, personnel records, and discussions with facility staff, the facility failed to ensure a written individual training plan, with input from both supervisor and the employee, was completed for each employee in two of nine personnel records reviewed.
Employee #8 was hired as a life skills staff member on August 22, 2023. There was no documentation that an individual training plan was completed for the current training year.
Employee #9 was hired as a life skills staff member on February 20, 2024. There was no documentation that an individual training plan was completed for the current training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In addition to the onboarding checklist used to track initial trainings. The Program Director will work with all new hires to create the individual training plan in the first 30 days of hire and monitor. All individual plans will be updated annually. |
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 Staffing Requirement Facility Summary Report, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training within the regulatory time frame in one of seven personnel records reviewed
Employee #10 was hired as a life skills specialist on July 1, 2021. The TB/STD training was due to be completed no later than July 1, 2023; however, there was no documentation that the training was completed as of the date of the inspection.
This is a repeat citation from the July 15, 2021, July 8, 2022, and July 24, 2023 annual licensing renewal inspections.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Although the staff had two attempts during the previous POC timeframe. Due to technical difficulties, the training was not completed.
Staff #10 previously completed HIV/AIDS training 12/12/2023 and completed the TB/STD training as of 5/17/24 and is now in full training compliance.
The program will continue to utilize the new hire checklist and individual training plan to monitor staff required trainings being completed in the appropriate timeframe by the Program Director. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of personnel records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to ensure all staff persons received the required HIV/AIDS training and TB/STD training within the regulatory timeframe were submitted and approved by the department for the July 15, 2021, July 8, 2022, and July, 24, 2023 annual licensing inspections. Failing to ensure that all staff received the communicable disease trainings within the regulatory timeframe was again found to be a deficiency in the May 6, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Current staff are now in compliance with DDAP training requirements. The program will continue to utilize the new hire checklist as well as the individual learning plan to ensure staff complete all trainings in the required timeframe. The Program Director will review and monitor all training plans. |