INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 25, 2024 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:
|
Plan of Correction
|
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
|
Observations
Based on a review of administrative information, the facility failed to document an assessment of staff training needs.
An assessment of staff training needs was not documented for the July 2023 to June 2024 training year. Additionally, the facility failed to document a policy and procedure for the assessment of staff training needs.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
At the beginning of each Fiscal Year, a meeting will be held with the Project Director, Facility Director, and the counselors to address that year's training needs and review expectations for that training year. Minutes from this meeting will be documented by the counselor and kept in a file to then use to assess the overall training plan for that Fiscal Year. The training plans will then be developed and signed by each participant and kept in the training file.
The counselor has written and implemented the annual training plan policy and procedure outlining 28 PA Code 704.11 Staff development program. |
704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of administrative information, the facility failed to document an overall plan addressing staff training needs.
An overall plan for addressing staff training needs was not documented for the July 2023 to June 2024 training year. Additionally, 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.
|
Plan of Correction
At the beginning of each Fiscal year during the annual training meeting each staff member (Project Director, Facility Director, and counselors) will discuss the subjects, or trainings that they would like to attend that year. The Counselor will serve as secretary for the meetings and take minutes. With the Assistance of all individuals at the meeting and the minutes the annual training plan will be developed. Each individual will be presented with staff plan and have the opportunity to adjust the plan or approve the plan. Once signed by all individuals these will go in the individuals training records. |
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.
|
Observations
Based on a review of personnel information, the facility failed to document a mechanism for collecting feedback on completed trainings in four of four records reviewed.
A mechanism to collect feedback on completed trainings was not documented for any staff members for the July 2022 to June 2023 training year. Additionally, the facility failed to document a policy and procedure for a mechanism to collect feedback on completed trainings.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The counselor will develop a Training Feedback work sheet by 7/30/24 to be reviewed by the Project Director, Facility Director and all other counselors that will be completed by each individual after a training has been attended. This worksheet will detail what the training was, summary of what the individual learned from the training, and if the training met the individual's expectations. The work sheet will then be put in the training file for the individual. |