INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted on February 15, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Genesis House 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)(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 four personnel records and discussion with the facility director it was determined that the facility failed to ensure that staff members completed a feedback form on all training attended.
The findings include.
Staff record #1 was hired on 04/04/2011. The training year for the facility includes 01/01/02011 to 12/31/2011. Staff # 1 failed to include feedback forms for training received for the 2011 training year.
|
Plan of Correction
Facility Director will review with all facility staff training requirements and procedures. Facility Director will monitor training evaluation completion by requiring the certificate to be attached to the evaluation. The certificate of completion will not be accepted without the training evaluation. A review of the staff charts will be done quarterly to ensure compliance. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill logs was conducted on February 15, 2012. The fire drills conducted from January 01, 2011 to 01/05/2012 were reviewed. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills.
An interview with the facility director was conducted on February 15, 2012. It was confirmed that the exit routes used was not alternated at least twice during the 01/01/2011 thru 01/01/2012 review. 01/11/2011 was the only back exit used during that period of review. 02/2011 to 01/05/2012 had the use of the front exit documented only.
|
Plan of Correction
Project Director will review with management the fire safety policy and procedure by 3/30/12. Project Director will review with all staff the alternative exit routes. The Project Director will review the Fire Drill Log quarterly to ensure the Clinical Director is using alternative exits at least twice within a fiscal year. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
|
Observations
Based on a review of personnel records and an interview with the project director, the facility failed to document annual performance evaluations as required by agency policy and regulation in one of four personnel records.
The findings include:
Four personnel records were reviewed on February 15, 2012 Two of the four personnel records were required to include documentation of annual performance evaluation. Per agency policy, performance evaluations are conducted at three months, six months and annually thereafter. There were no six month performance evaluations documented in personnel records #1 Employee #1 was hired on 04/04/2011 and required a six evaluation on 10/04/2011.
|
Plan of Correction
Project Director will create a spreadsheet notifying management when annual reviews are to be completed. Project Director will expect receipt of review from management and employee within 30 days of notification. Project Director will mark completed on the spreadsheet when the review is received and notify management if the review is not received within 30 days. Project Director will review with all management the personnel management policy by 3/31/12. |