INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 7, 2017 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, Little Creek Lodge 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual staff performance evaluation in 2 of 3 applicable personnel records.
Employee #2 was hired on 7/22/2015 as the Clinical Supervisor and was still in that position. There was no annual written individual staff performance evaluation documented for the employee since the previous licensing inspection.
Employee #5 was hired 6/17/2015 as a Counselor Assistant and was still in that position. There was no annual written individual staff performance evaluation documented for the employee since the previous licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual Performance Evaluations are typically performed at least once per year for any and all staff, and are accompanied by a performance-based pay increase. Ongoing performance monitoring of Clinical Staff was reflected in supervision notes. Moving forward, all employee performance evaluations will be performed on all Staff at least once per year. A written, objective evaluation that assesses 10 performance areas will be utilized. Each staff member will meet with their direct supervisor and the Clinical Director to review this evaluation.
These changes were put in place, effective 10/2/17. Annual Performance Evaluations for Employee #2 and Employee #5, occurred on 10/10/17. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records, the facility failed to provide written documentation that an individual treatment and rehabilitation plan was developed with a client in one of eight client records.
Client # 2 was admitted to treatment on 6/18/2017 and was discharged on 8/8/2017. The client's individual treatment and rehabilitation plan was not signed/dated by the client, thus it could not be verified that it was completed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client's involvement in the creation of his treatment plan was only documented by the clinician in the accompanying progress note. In order to demonstrate, not just through clinician report, that clients actively participate in the creation of their treatment plans, clients will be required to sign off on the progress note that accompanies the treatment plan.
This change was implemented on 10/02/17. The Clinical Supervisor and/or Clinical Director are responsible for reviewing charts on a weekly basis to insure the client's signature is present on Treatment Plan Creation progress note. |