INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 1, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Central Behavioral Health 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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704.11(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
The facility failed to collect feedback on completed trainings in two of three personnel records reviewed. Per the facility's policy, training evaluation forms are to be completed after each in-house training session.
Employee #1 was hired as the project director on November 30, 2014.
Employee #2 was hired as the facility director on April 27, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will immediately put the following line into section 704.11(a)(3) into the program's policy and procedure manual on 10/8/2019. All staff members of the program will be informed of this via email on 10/8/2019.
(3) Mechanism to collect feedback on completed training
After attending an in-house or external training staff members will verbally outline what was helpful about a recently attended training to either the program or facility director. They will also discuss whether it would be helpful to disseminate the information to other staff members at the agency.
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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
The facility failed to include an annual evaluation of the overall training plan, which is to include the completion timeframes and who is responsible for completion of the evaluation, in the facility's Staff Development Program policy and procedures.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility director will make the following change to 704.11(a)(4) in the programs policy and procedure manual on 10/8/2019 and will immediately make staff aware of this change via email.
(4) An annual evaluation of the overall training plan.
This evaluation should determine the extent to which the plan addressed the
identified needs.
-The annual plan will be reviewed and updated each October. The facility director will reach out to each staff member via email or phone to schedule a meeting for as many staff members to attend as possible. During that meeting the previous year's annual plan will be reviewed and any progress or lack of progress will be noted. The training needs for the overall program for the following year will be identified and the facility director will document them as well as time-frames for when they are to be completed.
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709.26 (a) (1) 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:
(1) Utilization of volunteers.
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Observations
The facility failed to develop and implement a policy and procedure that discusses the utilization of volunteers, as a part of their personnel management policy.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The following will be put into the program's policy and procedure manual by the facility director on 10/8/2019 and staff will be informed of the change via email.
709.26(a)(1)
The program will not utilize volunteers.
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