INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 3, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, North Philadelphia Health Systems, 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of personnel records and the staffing requirements facility summary report, the facility failed to provide documentation that an individual training plan, for the current training year, was developed with input from both the employee and the supervisor, in 1 of 10 personnel records reviewed.
Employee # 1 was hired as the Project Director on January 1, 2018. The training plan signed by the employee on February 22, 2020 did not include the supervisor's signature or other documentation that the supervisor provided input.
Employee # 2 was hired as a clinical supervisor on May 20, 2017. The training plan signed by the employee on January 9, 2020 did not include the supervisor's signature or other documentation that the supervisor provided input.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The annual training plan for the CEO was updated by the Sr. Vice President on August 13, 2020 to include the ongoing review/input and signature of the Chairman of the Board.
The 2020 Training plan of Employee #1 was sent to the Chairman on the Board for review/input and signature on August 13, 2020
The Sr. Vice President will monitor completion of plan on annual basis to ensure that citation does not reoccur.
The clinical supervisor will review with employee #2 for further input on their individual training plan.
Director will review all individual training plans for supervision signature or other documentation that the supervisor provided input prior to filing documentation in personnel file .
All personal file will be reviewed by 08/24/2020. |