INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 2009 and February 19, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Recovery Revolution, 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 March 13, 2009.
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Plan of Correction
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the agency procedures, agency contract for services, agency web-site and an interview with the project director the governing body failed to provide documentation that the 2007 -2008 annual report is available for public review.
The findings include:
A review of the agency policy and procedure manual, contract for services, agency web-site and an interview with the project director on February 19, 2009, there was no documentation that the annual report for fiscal year July 1, 2007 though June 30, 2008 was available for public review as of February 19, 2009.
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Plan of Correction
The project director was under the impression that posting on website was announcing the annual reports availability; however it was never officially publicly notified in print. For the 2008-2009 Annual report, the Project Director will place an advertisement in the local newspaper prior to November 2009. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the agency procedures, agency contracts for services, agency web-site information and an interview with the project director, the governing body failed to include a financial statement of income and expenses in the 2007- 2008 annual report.
The findings include:
A review of the agency policy and procedure manual, contract for services, agency web-site and an interview with the project director on February 19, 2009, the annual report for fiscal year July 1, 2007 though June 30, 2008 did not include a financial statement of income and expenses.
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Plan of Correction
The project director for the 2008-2009 Annual Report and future reports will include a financial statement regarding the income and expenses of the previous year's annual report. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel procedures, personnel records and an interview with the project director, the facility failed to include individual annual staff performance evaluations in two of two personnel records.
The findings include:
Four personnel records were reviewed on February 18, 2009. Two of the four records were required to have documentation of annual performance evaluations.
Personnel record # 3 - The employee was hired on February 8, 2007. An initial performance evaluation was completed in May 2007. The performance evaluation required for May 2008 was not documented in the personnel record as of February 18, 2009. An interview with the project director on February 19, 2009, requesting a copy of the May 2008 evaluation for personnel record # 3, confirmed that the document was not available.
Personnel record # 4 - The employee was hired on October 2, 2007. An annual performance evaluation was due on or by October 2, 2008. The performance evaluation required for October 2008 was not documented in the personnel record as of February 18, 2009. An interview with the project director on February 19, 2009 requesting a copy of the October 2008 performance evaluation for personnel record # 4 confirmed that the document was not available.
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Plan of Correction
The Executive Director or the Clinical Team Leader will evaluate all staff's performance at a minimum of a yearly basis. This evaluation will be in writing and the staff will have an opportunity to review the evaluation, make written comments, and sign the evaluation as proof of receiving the evaluations. Starting immediately, all staff will be evaluated on a yearly basis and a copy will be placed in their staff files. |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Based on a review of personnel records, the facility failed to document annual performance evaluations in two of four personnel records.
The findings include:
Personnel record # 3 - The employee was hired on February 8, 2007. An initial performance evaluation was completed on May 2007. The performance evaluation required for May 2008 was not documented in the personnel record as of February 18, 2009. An interview with the project director on February 19, 2009, confirmed that documentation of the evaluation was not available. Verification of a written copy of the annual performance evaluation was not provided for personnel record # 3.
Personnel record # 4 - The employee was hired on October 2, 2007. An annual performance evaluation was due on or by October 2, 2008. The performance evaluation required for October 2008 was not documented in the personnel record on February 18, 2009. An interview with the project director on February 19, 2009 confirmed that a copy of the October 2008 evaluation for record # 4 was not available. Verification of a written copy of the annual performance evaluation was not provided for personnel record # 4.
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Plan of Correction
The Executive Director or the Clinical Team Leader will evaluate all staff's performance at a minimum of a yearly basis. This evaluation will be in writing and the staff will have an opportunity to review the evaluation, make written comments, and sign the evaluation as proof of receiving the evaluations. Starting immediately, all staff will be evaluated on a yearly basis and a copy will be placed in their staff files. |
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 personnel training records and an interview with the project director, the facility failed to meet the general training requirements in one of two personnel training records.
The findings include:
Four personnel records and four training records were reviewed on February 18, 2009. Two of four were required to meet the general training requirements within one year of employment. One of the two personnel records failed to meet the general training requirements within one year of hire. An interview with the project director on February 19, 2009 confirmed that the Project Director could not provide documentation of the general training requirements.
Personnel and training record # 4 - The counselor was hired on October 2., 2007. A review of the training record on February 18, 2009 and an interview with the project director on February 19, 2009 confirmed that there was no documentation of the general training requirements of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics for that staff person. The general training requirements were to be met by October 2, 2008.
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Plan of Correction
The project director and clinical team leader will ensure that all of the employees have either documentation in the personnel records regarding previously attended training or attend an approved 6 hour training for HIV and 4 hour training for TB/STD wihtin one year of hire |