INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 8, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Horizon House, 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:
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Plan of Correction
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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 six personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #3 and #6 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #3 was hired as a counselor on 10/06/16 and was due to have the communicable disease trainings no later than 10/6/17. There no documentation in the personnel file of the completion of the required 6 hours of HIV/AIDS training or the required 4 hours of TB/STD training as of the date of the inspection.
Employee #6 was hired as a Peer Specialist on 11/4/13 and was due to have the communicable disease trainings no later than 11/4/15. There no documentation in the personnel file of the completion of the required 6 hours of HIV/AIDS training or the required 4 hours of TB/STD training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The DDAP required trainings of 6 hours of HIV/AIDS and 4 hours of TB/STD will be added to the staff Individual Training Plan which is completed annually by each staff with their supervisor.
At least semi-annually, the Program Administrative Assistant will compare the Staff Roster to the Individual Training Plans to ensure that all new staff receive the required trainings for HIV/AIDS and TB/STD. Any discrepancy will immediately be brought to the attention of the supervisor who will promptly address it.
The counselor (employee #3) is registered for the next HIV/AIDS training that is scheduled for 2/22/18. The counselor already took the TB/STD training on 9/25/17.
For the Peer Specialist (employee #6), he will attend the 2/22/18 HIV/AIDS and the 1/10/18 TB/STD trainings as a stand-by since both are closed to additional registrants. In the event that he is not able to take it on those days, he will be registered for the next available trainings once the dates are posted.
The Program Supervisor is responsible for ensuring that both staff attend the required training. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in one of five personnel records reviewed.
Employee #1 was hired as the project director on 10/01/00. There was no documentation of an annual work performance evaluation, signed and dated by the employee, in the personnel record as of the date of the inspection.
Employee #2 was hired as the facility director on 5/16/05. There was no documentation of an annual work performance evaluation, signed and dated by the employee, in the personnel record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Going forward, the Regional Director will ensure that the Facility Director receive an annual performance evaluation. The Administrative Manager will reconcile all Performance Evaluations and alert the Regional Director of all outstanding Evaluations. The Regional Director will promptly address all discrepancies.
The Project Director, who is the President/CEO of Horizon House, will work with the Board of Directors to obtain an annual performance evaluation. The Executive Assistance will monitor to ensure that the Project Director's Performance Evaluation is completed annually. Any discrepancy will be promptly discussed with the CEO (Project Director). |