INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 29, 2023 and June 30, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Passages to Recovery 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(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 staff records, the facility failed to ensure a written individual training plan for each employee is developed annually with input from both the employee and the supervisor in one of eight records.
Staff #6 was hired to the position of counselor on October 27, 2021 and was in this position at the time of review. Facility training year is January 1 through December 31. No Individual training plan was provided for staff #6 for the 2023 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individual Training Plans will be kept on file in the agency training binder. To maintain efficiency, this binder will be reviewed by Passages to Recovery's Compliance Officer to ensure that all staff are adhering to their training requirements and updated every December to include employee identified training needs. This will be reviewed by the Compliance Officer and provided to supervisors to review with employees. Staff development will be reviewed on an ongoing basis during supervisions in addition to frequent reviews of training plans. Supervisors will be notified every quarter of those staff members who are at risk of not being in compliance with the Staff Development Program policy by the Compliance Officer.
Staff #6 ITP was completed and signed as of 7/1/23 to run to the end of this calendar year. |
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 ensure counselor receive a minimum of six hours of HIV/AIDS and at least four hours of tuberculosis, sexually transmitted diseases and other health related topics training within their first year of employment.
Staff #6 was hired to the position of counselor on October 27, 2021 and was in this position at the time of review. Staff #6 had until October 27, 2022 to complete a six hour HIV/AIDS training. Staff #6 ' s record did not contain documentation that they completed a six hour HIV/AIDS training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff person #6 has provided the certificate of completion for the HIV/AIDS training. Additionally, employees will be required to have completed an approved DDAP HIV/AIDS training with the first year of employment for clinical staff and 2 years of employment for administrative staff members. All employees will be required to submit certificates of completion within 72 hours of completion or risk disciplinary action. Documentation will be kept by the employees direct supervisor and the Compliance Dept. will ensure mandatory staff trainings are met.
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