INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 2009 and July 27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clem-Mar House, 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 and a plan of correction is due on August 21, 2009.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of training records and interview with the facility director the facility failed to complete an assessment of staff training needs annually in three of seven records reviewed.
Findings:
Staff development procedures reviewed on July 23, 2009 indicate an assessment of staff training needs is completed annually between October 1 and October 31. Three of seven personnel and training records reviewed on July 23, 2009 failed to provide documentation of the annual assessment of staff training needs.
Record # 1 - The employee was hired on November 1997. The staff development record was reviewed on July 23, 2009. The facility failed to provide documentation of a annual assessment of training needs.
Record # 2 - The employee was hired on November 2006 and promoted to assistant facility director on May 26, 2008. The staff development record reviewed on July 23, 2009 failed to include documentation of an annual assessment of training needs.
Record # 3 - The employee was hired in August 2005 and promoted to team leader on May 20, 2008. The staff development record reviewed on July 23, 2009 failed to include documentation of a annual assessment of training needs.
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Plan of Correction
Each employee undergoes a written evaluation at the time of his anniversary date. At that time, the employee will also complete an assessment of training needs. A copy of this assessment will be maintained by the Office Manager in her office and will be reviewed by the Assistant Projec Director on a monthly basis to ensure thisa deficiency does not re-occur. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of training records and interviews with the facility director, the facility failed to establish an annual overall training plan to address staff training needs.
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Findings.
Staff development procedures reviewed on July 23, 2009 indicate an overall plan to address staff training needs is completed annually in the month of November. Interviews with the assistant facility director confirmed that the facility failed to produce an overall staff training plan for the period of November 2008 through November 2009.
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Plan of Correction
During the period November 2008 through November 2009, the Facility Directo inadvertantly failed to complete an overall staff training plan. October 5, 2009 the Facility Director will complete a staff training plan for the following year during the first week of October |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of training records and interviews with the facility director, the facility failed to document an annual evaluation of the overall training plan.
Findings:
Staff development procedures reviewed on July 23, 2009 indicate an evaluation of the overall training plan is completed annually in the month of December. Interviews with the assistant facility director confirmed that the facility failed to produce an evaluation of the overall staff training plan for the period of November 2007 through November 2008.
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Plan of Correction
During the period from November 2007 through November 2008, the Facility Director inadvertantly failed to complete an evaluation of the overall staff training plan. In the future, consistent with Facility policy, the Facility Director will complete an evaluation of the overall staa training plan, dur8ing the first week of December. |
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
Staff development procedures reviewed on July 23, 2009 indicate that an annual individual training plan will be developed for all employees. Three of seven personnel/training records reviewed on July 23, 2009 failed to include documentation of the annual individualized training plan.
Findings:
Record # 1 - The employee was hired on November 1997. The staff development record reviewed on July 23, 2009 failed to include documentation of a individualized training plan for calender year 2009.
Record # 2- The employee was hired on November 2006 and promoted to assistant facility director on May 26, 2008. The staff development record reviewed on July 23, 2009 did not include documentation of an individualized training plan for calender year 2009.
Record # 3 - The employee was hired in August 2005 and promoted to team leader on May 20, 2008. The staff development record reviewed on July 23, 2009 did not include an individualized training plan for calender year 2009.
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Plan of Correction
Each employee has a written evaluation at the time of there anniversary date. In the future at that time the employee will also develop an individualized training plan for the following year. A copy of each employees individualized training plan will be maintained by the Office Manager and kept in her office. These plans will be reviewed by the Assistant Project Director on a monthly basis to ensure that this deficiency does not occur in the future. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of staff development records and an interviews with the assistant facility director, the facility failed to ensure that staff acquired 4 hours of tuberculosis, sexually transmitted diseases and other heath related training within the first year of employment.
Findings:
Three of seven staff development records reviewed on July 23, 2009 failed to include documentation of 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training.
Record # 4. - The employee was hired on March 19, 2008. Based on a review of the staff development record, 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training had not been provided or documented.
Record # 5. - The employee was hired on July 5, 2008. Based on a review of the staff development record 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training had not been provided or documented.
Record # 7. - The employee was hired on June 4, 2008. Based on a review of the staff development record 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training had not been provided or documented.
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Plan of Correction
A list of trainings all staff has attended will be kept by the Office Manager and maintained in her office. The Assistant Project Director will review this on a monthly basis to ensure compliance with training regulations. These three employees wwill receive the required trainings by 12/01/09.
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