INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensing inspection that was conducted on July 30, 2019 thru August 1, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the supervisory review of findings from the on-site inspection, Eagleville Hospital 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 supervisory review:
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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
The facility failed to document a written training plan for employees 17 thru 63.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Vice President of Human Resources has implemented a new performance appraisal form to better capture staff goals and individualized training plans. Appraisals are to be completed by 10/11/19. HR will audit receipt and document completion of all appraisals including individual training plans by 10/18/2019. |