INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2018 through July 12, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Aldie Foundation 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:
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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
The facility failed to ensure that two staff persons received the required communicable disease trainings within the regulatory timeframe.
Employee #13 was hired as a counselor on July 5, 2016. The employee file did not contain documentation of the TB/STD training at the time of the inspection.
Employee #16 was hired as a client services representative on August 5, 2015. The employee file did not contain documentation of the TB/STD training at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Aldie has a DDAP approved TB/STD program and trainer on staff. The CEO has instructed the trainer to schedule a training for the affected staff no later than September 15, 2018. Staff will be required to attend and complete the training. The process will be monitored by the Operations Manager who is in charge of maintaining the staff training records. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
The facility failed to provide documentation that clients were oriented to the project during the intake/admission period in seven of fourteen client records reviewed.
Client #1 was admitted on August 11, 2017 and was active at the time of inspection.
Client #2 was admitted on October 16, 2017 and was active at the time of the inspection.
Client #3 was admitted on March 30, 2018 and was active at the time of the inspection.
Client #4 was admitted on August 11, 2017 and was discharged on October 4, 2017.
Client #5 was admitted on October 20, 2017 and was discharged on January 24, 2018.
Client #6 was admitted on June 27, 2017 and was discharged on November 15, 2017.
Client #7 was admitted on December 5, 2017 and was discharged on February 7, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Programming will ensure that all new clients are provided with an orientation. For individuals enrolling in a MAT program the MAT Coordinator will conduct the orientation. For non-MAT clients the Program Supervisor will conduct the orientation. The orientation sessions will be documented in the patient record with a clinical note. Compliance will be reviewed in supervision and as part of monthly chart audits. |