INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC Western Behavioral Health at Mon Yough 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of five applicable staff records.Staff #7 was hired as a counselor on April 10, 2022. The TB/STD training was to be completed by April 10, 2023. There was no documentation that this training was completed.This is a repeat citation from the October 24, 2022 and October 25, 2021 annual licensing inspections.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinician #7 is scheduled to complete the DDAP approved TB/STD/Hepatitis training on 1/30/24. This was the earliest training available. There is documentation of the registration. The Supervisor and Clinician #7 will work together to investigate if an opening becomes available prior to this date. Progress will be discussed at supervision meeting. Clinician #7 did complete the Basic HIV on 11/30/2018 and the certificate has been printed.
On 9/6/23, Program Director developed a new process for monitoring staff training, and reviewed this process with program supervisor, practice manager, and administrative support staff. Effective 9/6/2023, when newly hired staff are onboarding to Mon Yough, staff will sign an attestation that they understand the following:
1) what trainings need to be completed for their position within the first 365 days of hire (DDAP approved trainings)
2) the requirement of creating TMS and Train.org accounts,
3) that they and the Supervisor will create an annual training plan,
4) the requirement for completing an eval for all trainings,
5) they will send training certificates to identified personnel and
6) staff members will comply with completing the annual training required per regulatory standards.
On 9/6/23, Program Director created a training tracker form and reviewed it with Mon Yough leadership team. The program supervisor will review the employee's training needs and training completion during every supervision meeting, which will be documented on supervision notes, effective 9/20/23
|
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.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for completion of mandatory communicable disease trainings was submitted and approved by the Department for the October 24, 2022 and October 25, 2021 annual licensing inspections. Completion of mandatory communicable disease trainings was again found to be a deficiency in the September 5, 2023 annual licensing inspection.This was reviewed with the facility staff during the licensing process.
|
Plan of Correction
On 9/6/23, Program Director developed a new process for monitoring staff training, and reviewed this process with program supervisor, practice manager, and administrative support staff. Effective 9/6/2023, when newly hired staff are onboarding to Mon Yough, staff will sign an attestation that they understand the following:
1) what trainings need to be completed for their position within the first 365 days of hire (DDAP approved trainings)
2) the requirement of creating TMS and Train.org accounts,
3) that they and the Supervisor will create an annual training plan,
4) the requirement for completing an eval for all trainings,
5) they will send training certificates to identified personnel and
6) staff members will comply with completing the annual training required per regulatory standards.
On 9/6/23, Program Director created a training tracker form and reviewed it with Mon Yough leadership team. The program supervisor will review the employee's training needs and training completion during every supervision meeting, which will be documented on supervision notes, effective 9/20/23
|