INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Warren General Hospital 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) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of administrative information, the facility failed to document a policy and procedure for the overall plan addressing staff training needs.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The "Staffing Training" policy will be updated by July 11, 2025 to include the plan on addressing staff training needs by the facility director.
The manager will complete annual evaluations on each staff member to include training needs and goals. The manager will assist staff in obtaining education needs identified through each year. |
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 personnel information, the facility failed to document a mechanism for collecting feedback on completed trainings in two of two records reviewed.
A mechanism to collect feedback on completed trainings was not documented for any staff members for the July 2023 to June 2024 training year.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the June 25, 2024 annual licensure inspection.
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Plan of Correction
The staff will be educated that they have to complete a follow-up evaluation for any education provided outside of Warren general Hospital. These forms will be turned into the counselor. The drug and alcohol counselor will keep these file for each employee. The facility director will review any education and follow-up form evaluation with the counselor for 3 months and randomly for the next year to monitor for compliance. |
710.23(a) LICENSURE Patient Records
§ 710.23. Patient records.
(a) In addition to the requirements contained in § 115.32 (relating to contents), the patient ' s medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an attempted follow up with clients following discharge in three of seven records reviewed.
According to agency policy and procedure, follow up with all discharged clients is completed within 15 days.
There were no follow up attempts documented on the following clients.
Client #4 admitted on March 19, 2025 and discharged on March 20, 2025.
Client #6 admitted on January 7, 2025 and discharged on January 8, 2025.
Client #7 admitted on April 7, 2025 and discharged on April 10, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The detox counselor or delegate will complete follow-up with clients within 15days of discharge. This will be documented in a follow-up log book.
The facility director will audit 50% of discharged detox patient charts for 3 months. Will continue to randomly monitor charts for compliance of policy.
The Follow-Up Policy will be printed and education will be provided to all staff with a sign-off sheet stating they have read and understand the policy and will comply with it. |