INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensing inspection that was conducted on September 9 - 10, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on a supervisory review of findings from the on-site inspection, Northeast Treatment Centers, 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 supervisory review and a plan of correction is due.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report Form, the facility failed to document an annual written individual training plan for each employee.
The findings include:
The Staffing Requirements Facility Summary Report Form was completed by the facility on September 9, 2015. Based on the staffing form the inpatient facility failed to document an individual training plan for each employee.
The facility failed to document an individual training plan for all support staff that was documented on page seven of the staffing requirements facility summary report form.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The inpatient facility failed to document an individual training plan for all support staff listed on page seven of the staffing requirements facility summary report form.
The director for the inpatient unit did not include the documentation of the training plans for the staff listed on page 7 of the Staff Requirements Facility Summary Report. Training plans were completed for all full time staff, but not documented on the staffing form. The inpatient director will complete training plans for part time staff by 11/13/15. In addition, the PI/QA Coordinator will ensure in the future that all required information is documented on the Staffing Requirements Facility Summary Report prior to the report being submitted to DDAP for inspection review.
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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 the Staffing Requirements Facility Summary Report Form, the facility failed to ensure that 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 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.
The findings include:
The Staffing Requirements Facility Summary Report Form was completed by the facility on September 9, 2015. The outpatient facility failed to ensure all staff persons and volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours TB/STD training.
The Facilities Technician Team Leader was hired on October 27, 2008 and was required to receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training by October 27, 2010. There was no documentation of this training at the time of review on September 9, 2015.
Facilities Technician, D.L was hired on March 11, 2013 and was required to receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training by March 11, 2015. There was no documentation of this training at the time of review on September 9, 2015.
Facilities Technician, O.M was hired on February 25, 2013 and was required to receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training by February 25, 2015. There was no documentation of this training at the time of review on September 9, 2015.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Staffing Requirements Facility Summary Report completed by the facility September 9, 2015 failed to include the documentation for all the staff who were required to have received at least 6 hours of HIV/AIDS training and 4 hours of TB/STD training.
Facilities Technician Team Leader was to have received these trainings no later than October 27, 2010. The staff person actually received 6 hours of DOH approved training on HIV Disease June 29, 2009 and 4 hours of DOH approved training on TB/Hepatitis/STD on July 20, 2009.
Facilities Technician LD was to have received these trainings no later than March 11, 2015. This staff person actually received 4 hours of DOH approved training on TB/STDs/Hepatitis Viruses on January 22, 2015 and 6 hours of DOH approved training on HIV/AIDS on February 10, 2015.
Facilities Technician OM was to have received these trainings no later than February 25, 2015. This staff person actually received 4 hours of DOH approved training on TB/STD on November 14, 2014 and 6 hours of DOH approved training on HIV/AIDS on October 11 and 24, 2014.
It is the responsibility of the PI/QA Director to review and assure that all staff receive the mandated trainings in a timely manner. It is also the PI/QA Coordinators responsibility to assure all training documents are turned in for the training files and documented on the Staffing Requirements Facility Summary Report prior to submission to DDAP for an inspection.
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