This report is a result of an on-site licensure renewal inspection conducted on April 16, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial 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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Observations
Based on a review of three of seven applicable personnel records, the facility failed to provide documentation of at least 25 clock hours of annual training required for a counselor for the training year July 2022-June 2023 for employee # 4 and #5.
Employee # 4 was hired as a counselor on March 10, 2010, and promoted to lead counselor September 21, 2021. After a review of employee # 4 ' s personnel record, there were only 9 training hours documented.
Employee # 5 was hired as a counselor on October 4, 2021, and was still in this position at the time of the inspection. After a review of employee # 5 ' s personnel record, there were only 10.5 training hours documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Operations will conduct semi-annual audits of employee training plans. These audits will include the progress of employees acquiring their required training hours and core trainings. At time of audit, information will be shared with the individual employees and department supervisors. Required training hours for positions are reviewed annually at the time of training plan development. Director of Operations will be responsible for assuring compliance with required training hours. |