INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 21, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health 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, the facility failed to provide documentation of TB/STD training in two of two personnel records.
The findings include:
Five personnel records were reviewed on February 13, 2013. Two personnel records were reviewed for documentation of TB/STD training. The facility failed to document TB/STD training in personnel records # 4 and 5.
Employee # 4 was hired for the position counselor on July 1, 2010. TB/STD training was due to be completed no later than July 1, 2011. There was no documentation of TB/STD training in personnel record # 4, as of February 13, 2013.
Employee # 5 was hired for the position counselor on January 9, 2012. TB/STD training was due to be completed no later than January 9, 2013. There was no documentation of TB/STD training in personnel record # 5, as of February 13, 2013.
The facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the February 22, 2012 licensing inspection.
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Plan of Correction
Employees #4 and #5 will be scheduled immediately for the next available TB/STD training.
It shall be the responsibility of the clinical supervisor to insure ongoing compliance with this regulation through routine reviews of trainings plans and employee training files.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director and facility director in two of two personnel records.
The findings include:
Five personnel records were reviewed on February 13, 2013. Two personnel records pertained to the project director and facility director and required documentation of 12 clock hours of annual training. The training year reviewed was from July 1, 2011 through June 30, 2012. The facility failed to document 12 clock hours of annual training for the 2011/2012 training year in personnel records # 1 and 2.
Employee # 1 was hired as the project director on July 1, 1978. Personnel record # 1 did not include documentation of any training hours for the 2011/2012 training year, as of February 13, 2013.
Employee # 2 became the facility director on July 16, 2004. Personnel record # 2 only included documentation of 6 training hours for the 2011/2012 training year, as of February 13, 2013.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Project Director has received 7 hours of training and Facility Director has obtained 12 hours of required training this calendar year.
Project Director will obtain the remaining hours to meet the 12 hours of required training. Project and Facility Director will insure ongoing compliance with this regulation.
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