INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 12, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.Based on the findings of Part 1, an abbreviated off-site inspection, PERSAD 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 eight personnel records, the facility failed to provide documentation of an individual training plan for employee # 1.Employee # 1 was hired as the Project Director on March 20, 2019. An individual training plan was not developed for the employee until August 5, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 had not been included in the creation of training plans. Going forward a training plan for Employee #1 will be updated annually along with the clinical staff, this will be done by the Clinical Supervisor. When/if a new person enters the position of Executive Director, a training plan will be created for this individual within 30 days of hire. The Clinical Supervisor will be responsible for making sure this occurs. |
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 eight personnel records, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training within the regulatory timeframe for employee # 1.Employee # 1 was hired as the Project Director on March 20, 2019, a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training was due no later than March 20, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 created a log-in for DDAP trainings and will complete the 2 trainings as soon as they become available through the DDAP training management system. Employee #1 is expected to complete these by 1/1/2021. The Clinical Supervisor will monitor to ensure completion of trainings. If a new person enters into the position of Executive Director we will make sure these trainings are completed within the first year of employment. This will be monitored by the Clinical Supervisor. |
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 eight personnel records, the facility failed to provide documentation of annual performance evaluation for employee # 1.Employee # 1 was hired as the Project Director on March 20, 2019. An annual performance evaluation was due no later than March 20, 2020.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An annual evaluation for Employee #1 will be completed by 10/31/2020 by employee #1's direct supervisor. A performance evaluation will be completed each year by the 31st day of October for Employee #1 by his direct supervisor. The Clinical Supervisor will ensure completion of this. |