INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 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, Holcomb Associates, 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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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 files, the facility failed to ensure that the file for employee #2, who was hired as the facility director on 05/11/15, contained any documentation of an annual written individual performance evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Holcomb Behavioral Health Systems (HBHS) experienced a management team transition from 7/2016 through 1/2017. The transition between the outgoing project director (HBHS COO) to the incoming project director (HBHS COO promotion to HBHS COO) occurred during this time. The outgoing project director did not complete the annual evaluation.
HBHS does have policy and procedures in place for conducting Annual Evaluations for all employees. This process is overseen by the Director of Human Resources. The Director of Human Resources will review the personnel chart of the facility director with the project director on an annual basis to ensure that all annual evaluations for the facility director are completed and placed in the employee file.
The performance evaluation will be completed for employee #2 on 6/16/2017. This Plan of Correction is effective 6/15/2017. |