INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 05/31/2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, Depaul House LLC LZUK6701 was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing. Therefore, deficiencies were identified during this inspection, and a plan of correction is required.
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Plan of Correction
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§ 717.17(b)(4) LICENSURE Personnel Management
§ 717.17. Personnel management.
(b) The written policies and procedures must include:
(4) Orientation of new employees.
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Observations
Based on a review of staff records the recovery house failed to include a staff orientation in 1 of 4 staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
I (Associate Director) have registered all staff members to complete all DDAP required training. AD will require all new staff and/or volunteer to complete all DDAP required training within the appropriate timeline. AD will review all staff records quarterly and ensure all staff records comply with DDAP requirements. All current employees will be updated by the 30th of June. |
§ 717.18(c)(3) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on a review of staff records, the recovery house failed to have staff complete the tuberculosis and sexually transmitted diseases training using a department approved curriculum within the first 90 days of hire in 1 of 4 staff records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
I the AD (Associate Director) will require all new staff and/or volunteer to complete all DDAP required training within the 90 day timeline. AD will review all staff records quarterly and ensure all staff records comply with DDAP requirements. All current employees not in compliance with DDAP training curriculum will be take necessary training by the 30th of June. Moving forward I will perform a quarterly check of the employee files to ensure all training and paperwork are up to date. |