INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BI Incorporated 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 February 25, 2011.
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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 2009-2010 annual report and an interview with the project director, the governing body failed to make available to the public the 2009-2010 annual report.
The findings include:
The 2009-2010 annual report was due for review on January 27, 2011. The facility is publicly funded and required to make available to the public an annual report. In an interview, the project director reported the 2009-2010 annual report was not completed. The governing body failed to make the 2009-2010 annual report available to the public, as required.
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Plan of Correction
The facility director will be responsible for making available a public report detailing the activities and accomplishments of the last year, a financial statement of income and expense, and a statement disclosing the names of officer, directors and shareholders. This will be completed by 12/31/11.
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709.23(b)(2) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(2) Written reports of project operations.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document current board meeting minutes.
The finding include:
A review of the facility's policy and procedure manual and an interview conducted on January 27, 2011 with the Project Director confirmed that the facility could not produce current board of director meeting minutes for the last 12 months.
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Plan of Correction
The project director will be responsible for gathering meeting minutes from the governing body that include board members, board meeting minutes, achievements, goals, and public monies received for the project. This will then be forwarded on to the facility director and included in the public report. This will be completed by 12/31/11. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records and an interview with the facility director, the facility failed to document the results of a reference investigation in four of four personnel records, as required.
The findings include:
Four personnel records were reviewed on January 27,2011. Four personnel records required reference investigations. Per regulation, the personnel records shall include the results of reference investigations. Personnel records # 1, 2# 3# and 4 failed to include the results of a reference investigation.
Employee # 1 was hired on April 1, 1992. There was no documentation of a reference investigation in personnel record # 1.
Employee # 2 was hired on July 31, 2001. There was no documentation of a reference investigation in personnel record # 2.
Employee # 3 was hired on June 6, 2010. There was no documentation of a reference investigation in personnel record # 3
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Employee # 4 was hired on September 13, 2010. There was no documentation of a reference investigation in personnel record # 4
The facility director was interviewed on January 27, 2011 and confirmed the facility failed to document reference investigations for employees # 1, 2, 3, and 4.
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Plan of Correction
The project director has instructed the facility's human resources department to complete reference checks and for each employee file to have a letter verifying completion. The facility director will be responsible for obtaining a copy of this letter and placing it in the personnel file. This will be completed by 03/01/11. |
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 agency training files, the facility did not comply with this regulation. No documentation was available of the assessment of staff training needs for the current training year 2011.
The findings include:
A conversation with the Project Director on January 27, 2011 and a review of project personnel records confirmed the facility failed to have an assessment of staff training needs available for review.
Personnel files #1, 2, 3 and 4 failed to have staff training assessment included in personnel files.
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Plan of Correction
The facility director will meet with the lead counselor to discuss observed training needs identified and seek feedback from the employee on their training goals. The facility director will be responsible for having each staff member complete and submit a training needs assessment. The results of the assessment will be reflected in the employee's Individual Training Plan and Overall Training Plan. This will be completed by 12/31/11. |