INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2017 through July 12, 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, Libertae Family House Libertae, 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of 5 personnel records, the facility failed to document an annual individual training plan for the facility's current training year in employee #1's record. Employee # 1 was hired as the project/facility director on 5/4/2015 and was still in the position at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The annual individual training plan for employee #1 will be completed by August 30, 2017.
The plan to correct this deficiency is for the Board of Directors/Employee #1 to schedule the annual individual training plan tone completed within 30 days of the hire date for employee #1 or within 30 days of 5/4. |
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 records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #1 and #5 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 #1 was hired as the project/facility director on 5/4/15 and was due to have the communicable disease trainings no later than 5/4/17. There was no documentation in the personnel file of the completion of the HIV/AIDS training or the TB/STD training as of the date of the inspection.Employee #5 was hired as a treatment tech on 7/17/14 and was due to have the communicable disease trainings no later than 7/17/16. There was no documentation in the personnel file of the completion of the HIV/AIDS training or the 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
Employees #1 and #5 will be scheduled to attend the next available HIV/AIDS and TB/STD training for the minimum of 6 hours and 4 hours respectively. The documentation of these trainings will be filed in each of the employees' personnel records and available for inspection.
The time frame for the correction of this deficiency is 11/30/17. |
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 1 of 5 personnel records reviewed.Employee #1 was hired as the project/facility director on 5/4/15. 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
The annual work performance evaluation for employee #1 will be completed by August 30, 2017.
The plan of correction for this deficiency will be for the Board of Directors/Employee #1 to schedule this annual review within 30 days of the hire date of 5/4 each year. |