INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 22-23, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Addiction and Behavioral Counseling Associates LLC DBA Matrix Treatment Center, 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 ensure employees received the minimum of at least 6 hours of HIV/AIDS training within the first year of employment in one of eight records.
Staff #4 was hired as a counselor on May 1, 2023, and still employed at the time of inspection. Staff #4 was due to have the communicable disease trainings no later than May 1, 2024. There was no documentation provided of the completion of the HIV/AIDS training as of the date of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward
Facility Director will ensure that all required DDAP trainings will be completed within the required timeframe. Staff #4 and all newly hired staff will complete the HIV/AIDS training. DDAP training login was provided to all staff . |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of administrative information, the facility failed to ensure CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.
The following dates and times did not have staff people who were CPR certified or trained in first aid:
June 2, 2024, from 7am-3pm
June 16, 2024, from 3pm-11pm
June 22, 2024, from 7am-11am and from 7pm-11pm
June 23, 2024, from1pm-11pm
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward
Facility Director will ensure that all shifts will have a CPR certified staff scheduled. CPR certification courses will be provided to all staff. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to include the type and frequency of treatment and rehabilitation services on the treatment plan in seven of seven residential records.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Immediately and moving forward
the frequency of treatment and rehabilitation services will be
implemented into the treatment plan. This will be
monitored by routine chart audits. Treatment plan will now reflect to show the following : Client will attend daily groups and individual sessions at least once a week to process and help her to gain education and insight into her history of chemical use to identify triggers and risks to her maintaining and sustaining sobriety 100% of the time as required until discharge.
Facility Director will conduct chart
audits on a routine basis. |