INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 13, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Wyoming Valley Alcohol and Drug Services, 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:
|
Plan of Correction
|
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
|
Observations
Based on the review of personnel records, the facility failed to ensure that a semiannual performance evaluation was completed for each counselor assistant. Ten personnel records were reviewed on March 13, 2017, five of which were identified as counselor assistants. Employee #8 was hired as a counselor assistant on August 2, 2016. A semiannual performance evaluation was due on February 2, 2017 but was not completed. Employee #9 was hired on July 25, 2016. A semiannual performance evaluation was due on January 25, 2017 but was not completed. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
WVADS HAD MISSED THIS REQUIREMENT. SINCE LICENSING HAD LEFT WE MET AS A SUPERVISORY STAFF AND IMPLEMENTED A PLAN THAT WOULD HAVE THE SUPERVISOR OF THAT DEPARTMENT COMPLETE A SEMI-ANNUAL EVALUATION ON THAT COUNSELOR ASSISTANT. THIS TOOL HAS ALREADY BEEN CREATED BY THE AGENCY CEO THAT UTILIZES VARIOUS MEASURES TO GAUGE PERFORMANCE AND READINESS TO BECOME A COUNSELOR. THIS WOULD BE COMPLETED BY THAT DEPARTMENT SUPERVISOR BETWEEN THE 5TH AND 6TH MONTH OF EMPLOYMENT. IT WOULD THEN BE REVIEWED WITH THE COUNSELOR ASSISTANT SO THAT PROGRESS COULD BE MEASURED. IN ADDITION, ALL EMPLOYEES ARE GIVEN AN ANNUAL EVALUATION USING VARIOUS MEASURES TO GAUGE PERFORMANCE. THESE EVALUATIONS WILL SIGNED BY THE COUNSELOR ASSISTANT, SUPERVISOR AND CEO. IT WILL ALSO BE PLACED INTO EMPLOYEES CHART FOR REVIEW AT ANY TIME. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120F.The physical plant inspection took place on March 13, 2017. The hot water in the staff bathroom read at 139F at approximately 9:30am and at 140F at approximately 3:30pm. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
SINCE LICENSING HAD LEFT, WE HAVE PURCHASED THERMOMETERS THAT WILL ALLOW US TO MEASURE WATER TEMPERATURE. THE CEO IN CONJUNCTION WITH THE FISCAL SUPERVISOR WILL TEST THE WATER TEMPERATURE ON A WEEKLY BASIS TO ENSURE THAT IT DOES NOT EXCEED 120F. THE TESTING WILL BE DOCUMENTED ON A WEEKLY BASIS. IN ADDITION, WE HAD OUR HVAC COMPANY TURN DOWN THE WATER TEMPERATURE ON THE HOT WATER HEATER SHORTLY AFTER LICENSING COMPLETED THEIR INSPECTION. IT WAS TESTED BY THE CEO AND THE TEMPERATURE WAS 119F.OUR HVAC COMPANY ALSO ENSURED US THAT THEY ARE AVAILABLE FOR ADJUSTMENT WHENEVER NECESSARY. IN REVIEW, THIS ISSUE HAS ALREADY BEEN ADDRESSED AND WATER TEMPERATURE IS NORMAL. |