INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 7-8, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Choices, LLC 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 staff records, the facility failed to document TB/STD training within the first year of employment for counselors in one of one staff records.
Staff #3 was hired as a counselor on March 28, 2022. TB/STD training was due to be completed by March 28, 2023. There was no documentation of TB/STD training in staff record #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will include mandatory training checklist with initial hire information and will monitor for compliance with completion of training if available or registration to soonest training available from hire. If no trainings are available within the required timeframe for completion, Facility Director will have medical personnel on staff to provide training as needed following the DDAP Curriculum guides available. Facility Director will monitor for compliance through chart audits and will maintain documentation onsite as needed for review. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in two of five client records.
Client #5 was admitted on April 20, 2023 and is currently an active client. There was no psychosocial evaluation documented in client record #5.
Client #12 was admitted on February 27, 2023 and is currently an active client. There was no psychosocial evaluation documented in client record #12.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director &/or Clinical Supervisor will provide staff with training related to completion of psychosocial documentation including timeframe for completion. Training information will be maintained onsite for review and completion of psychosocial documentation will be monitored through random chart audits of patient admission charting. Chart Audits will be completed by either the Clinical Supervisor, Facility Director or through peer review of documentation. Training and plan will be implemented by 9/22/23. |