INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 06, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, CLEM-MAR INC., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on a review of the facilities rules of conduct policy and procedure and interviews with facility staff on May 6 and 7, 2021, the facility failed to ensure that staff were following rules of conduct when it came to the wellbeing of staff.
The complainant submitted a letter to DDAP stating that they were sexually harassed by a co-worker on the following dates 11/12/2020, 11/20/2020 and two times on 12/1/2020. During the interview with facility staff it was confirmed that this took place, but there was no documentation in the employee's personnel record nor a follow-up that this was address with the facility staff person in questioned.
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Plan of Correction
The Clinical Supervisor will place all information into the identified employees file of the complaint, the response, and outcome of the meeting regarding the complaint. This information will be placed in both the employees and the complainants file. Both the Clinical Supervisor as well as the Department Supervisor will be responsible for ensuring this is in compliance with the rules and regulations. In addition all staff will be reminded during staff meetings of the importance of adhering to our policies regarding sexual harassment in the work place. The Rules Of Conduct and the Sexual Harassment policy will be given to each staff member and, will be strictly adhered to with any future incidents. The complaint process will be overseen by The Project Director. Should any further incidents occur, all parties involved will follow all steps in the Sexual Harassment policy and meetings and results of those meetings will be documented and placed in employee files. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of the facility ' s unusual incident reports and interviews with facility staff on May 6 and 7, 2021, the facility failed to submit an unusual incident reporting sexual harrasment.
The complainant submitted a letter to DDAP stating that they were sexually harassed by a co-worker on the following dates 11/12/2020, 11/20/2020 and two times on 12/1/2020. During the interview with facility staff it was confirmed that this took place.
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Plan of Correction
The Clinical Supervisor will submit an Unusual Incident Report to DDAP regarding any reports of sexual harassment occurring in the work place within three business days following notification of the incident and submit the outcome of the process to DDAP. Both the Clinical Supervisor and the Project Director will review any complaints of this nature in their weekly meetings to ensure compliance with this regulation.
The Project Director shall ensure adherence to this regulation. All Staff will be given a copy of The Rules Of Conduct and Sexual Harassment policy immediately. They will be encouraged to report any incidents to the Team Lead who, will notify the Clinical Supervisor. The Project Director will oversee that the entire process adheres to our Rules Of Conduct and Sexual Harrassment policy. |