INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alternative Counseling Associates, 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 the review of the facility-submitted Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the regulatory timeframe in 2 of six personnel records reviewed.
Employee #5, an administrative assistant hired on May 13, 2019, was due to receive both the minimum of six hours of HIV/AIDS training and the four hours of TB/STD training no later than May 13, 2021; however, there was no documentation that either the HIV/AIDS or TB/STD trainings were completed as of the date of the inspection.
Employee #6, a resident monitor hired on July 19, 2019, was due to receive both the minimum of six hours of HIV/AIDS training and the four hours of TB/STD training no later than July 19, 2021; however, there was no documentation that either the HIV/AIDS or TB/STD trainings were completed as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Agency was well aware of the training needs identified; the Director reviews such at least annually.
Available trainings with open space were difficult to secure during the pandemic year.
Employee #6 has left employment with the agency. Employee #5 is scheduled for Montgomery Co SCA sponsored trainings as follows: TB/STD/Other topics, November 2021; HIV/AIDS January 2022. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in one of seven client records reviewed.
Client # 2 was admitted on July 26, 2021 and was still active at the time of inspection. A release of information form to a pharmacy was signed and dated by the client on July 26, 2021; however, there was no documentation in the record that indicated a copy was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately upon becoming aware, Client #2 was addressed with form and completion occurred 10/1/21.
Charts are reviewed by the counselor and director a minimum of one time at a plan review and update time. It is the responsibility of the counselor and director to ensure paperwork is complete in entirety. |