INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, T. W. Ponessa and Associates Counseling Services, 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 and a plan of correction is due on September 10, 2009.
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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 provide documentation of HIV training within the first two years of employment for support staff in one of one personnel records reviewed.
The findings include:
Four personnel records were reviewed on August 17, 2009. Four personnel records were required to have documentation of HIV training. One of one support staff was required to have HIV training by March of 2009. The facility did not provide documentation that employee # 4 had received HIV training.
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Plan of Correction
Effective September 1, 2009, the Facility Director will meet bi-monthly with the support staff Coordinator to: review each support staff training plan; identify incomplete trainings; & determine plan of action (that is: date, time, & location) for securing completion certificates. Meeting minutes will be maintained. To correct this citation, support staff Coordinator will take responsibility to regularly peruse the BDAP Upcoming Training wedsite for HIV training announcements. Also, Facility Director will forward any HIV training announcement emails to the support staff coordinator. Support Staff Coordinator will notify Facility Director when employee #4 has been scheduled for HIV training. Support staff coordinator will ensure employee #4 secures an HIV training certificate by 12/1/09. Facility Director will update Project Director of support staff training status in weekly supervision. Project Director will intervine as needed. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure and document that the project director and facility director completed at least 12 hours of training for the training year 2008 in one of one two records reviewed.
Findings:
Four personnel records were reviewed on August 17, 2009. Two personnel records were required to have at least twelve hours of annual training documented for the facility's 2008 training year. Only 10.5 hours of annual training was documented in personnel record #1.
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Plan of Correction
Project Director will take responsibility to ensure 12 hours of annual training are secured by administrative staff & that the trainings are appropriately documented in the personnel charts. The Project Director will review the administrative training status will be conducted in the administrative weekly supervision. The quarterly report written by the Facility Director contains administrative training information & will continue to be utlized as a monitoring instrument. The Project Director will sign-off on the quarterly reports.Presently, 14 hours of training are documented in personnel record #1 for the 2009 training year. |