INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on February 17, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Genesis House(Harrisburg) 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:
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Plan of Correction
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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review personnel records, the facility failed to ensure that a counselor assistant documented to the facility director that he is working toward counselor status.
The findings include:
Three personnel records were reviewed on February 17, 2012. Counselor Assistant documentation of working toward counselor status was required in one personnel record. The counselor assistant did not document to the facility director that she is working toward counselor stats in personnel record # 3
The counselor assistant was hired on 08/31/2011. The documentation of the counselor assistant working toward the position of counselor was due by 12/31/2011.
An interview with the Project Facility Director on February 17, 2012 confirmed the staff was unaware of this regulation and failed to complete this documentation.
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Plan of Correction
Project Director will review with all facility staff the DOH staffing requirements and the employee requirements by 3/31/12. The Project Director will add to the personnel management spreadsheet staff development counselor status and review monthly for due dates. Project Director will expect receipt of development of counselor status from employee within 30 days of notification. Project Director will mark completed on the spreadsheet when the letters is received and notify employee if the review is not received within 30 days. |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of four personnel records and discussion with the facility director it was determined that the facility failed to ensure that staff members completed a feedback form on all training attended.
The findings include:
Staff record # 1 failed to include feedback forms from training's completed in the January 1, 2011 to December 31, 2011 training year.
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Plan of Correction
Facility Director will review with all facility staff training requirements and procedures by 3/31/12. Facility Director will monitor training evaluation completion by requiring the certificate to be attached to the evaluation. The certificate of completion will not be accepted without the training evaluation. A review of the staff charts will be done quarterly to ensure compliance. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on review of the written letters of agreements, the facility failed to update the signatures of primary referral sources.
The findings include:
Review of written letters of agreements on February 17, 2012, the facility failed to renew the written letters of agreement with the primary referral sources. The written letters of agreements expired in January 2012.
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Plan of Correction
Project Director will schedule a face to face meeting with the administration of the facilities that have expired written agreements to secure a signed referral agreement by 3/31/12. Project Director will place signed agreement in the referral agreement binder for licensing review. |
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 the personnel records, the facility failed to evaluate staff as per policy.
The findings include:
Review of three personnel records on February 17, 2012, the facility failed to have staff record # 1 have a six month individual staff performance evaluation included in their file. As per facility policy, new employees have an evaluation completed six month from the date of hire. Employee #1 was hired on 04-04-2011. The evaluation due date was 10-04-2011; their was no documentation of this evaluation available at the time of the inspection.
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Plan of Correction
Project Director will create a spreadsheet notifying management when annual reviews are to be completed. Project Director will expect receipt of review from management and employee within 30 days of notification. Project Director will mark completed on the spreadsheet when the review is received and notify management if the review is not received within 30 days. Project Director will review with all management the personnel management policy by 3/31/12. |