INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on March 4 th through March 8, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Livengrin Foundation, Inc.(Bensalem) 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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709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based upon a tour of the facility, the facility failed to have the fee schedule posted in a prominent place.
The findings include:
On March 5, 2013 at 1:00 P.M. a physical plant tour was conducted. The licensing specialist was unable to find the fee schedule posted and asked for the location of the posted fee schedule. An employee at the front desk confirmed that the fees were not posted.
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Plan of Correction
The fee schedule is posted in the admissions area. In the future, the Director of Compliance and Licensing will train all Bensalem staff during Staff Orientation to be aware that the fee schedule is posted in the Admissions area. Additionally, The Director of Compliance and Licensing will ensure that the Facilities Maintenance Manager will take the licensing specialists to the admissions area during the physical plant tour. |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Based on a review of personnel records, the facility failed to document annual performance evaluations as required by agency policy and regulation in three of fourteen personnel records.
The findings include:
Fourteen personnel records were reviewed on March 4, 2013. Fourteen personnel records were required to include documentation of annual performance evaluations. Per agency policy, performance evaluations are conducted at three months and annually thereafter. There were no annual performance evaluations documented in personnel records #1 and 2. Personnel record #5 did not include a three month evaluation.
Record #1(PD) was hired October 26, 1987. No evaluation was completed the past two years. Record #2 (FD) was hired on September 3, 2001. The last evaluation was completed on December 10, 2010. Both employees failed to have an annual review completed for 2012 . Record #5 was hired on August 27, 2012. The employee failed to have a three month evaluation completed.
An interview with the Director of Compliance and Licensing confirmed this finding on March 8, 2013.
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Plan of Correction
The Human Resources Director will ensure that evaluations are sent to supervisors on an annual basis and for new hires three months after hire. The Director of Compliance and Licensing will be responsible for Oversight, by confirming, on a monthly basis that all yearly evaluations and three month evaluations have been sent and returned. #2 and #5 evaluations have been sent to the supervisors and returned to Human Resources, confirmed by the Director of Compliance and Licensing. #1 - the president/CEO will meet with the Board on 4/25/13. His evaluation will be completed and sent to Human Resources. The Director of Compliance and Licensing will confirm that it has been sent to Human Resources. |