INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gate 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:
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Plan of Correction
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee received the required training in the use of the fire extinguishers upon employment.
Employee #5 was hired on March 6, 2023 for the position of counselor assistant and was still employed at the time of the inspection. She did not have the training until March 22, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (c) (4), the following will be implemented:
Beginning on 12/28/2023, the HR Generalist will ensure that all new hires receive training in the use of a fire extinguisher within their first week of employment. The HR Generalist will file the completion of the training in the employees record.
The Executive Director will monitor the progress of this action step during monthly supervision with the HR Generalist. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure one employee received the required training to perform assigned tasks during emergencies.
Employee #5 was hired on March 6, 2023 for the position of counselor assistant and was still employed at the time of the inspection. She did not have the training until March 22, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
In an effort to address citation 705.10 (d) (3), the following will be implemented:
Beginning on 12/28/2023, the HR Generalist will ensure that all new hires receive training in emergency procedures and task within their first week of employment. The HR Generalist will file the completed training in the staff record.
The Executive Director will monitor the progress of this action step during monthly supervision with the HR Generalist. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to complete an annual written individual staff performance evaluation, a copy of which shall be reviewed and signed by the employee.
Employee #1 was hired as the Project Director on October 2, 2017 and was still employed at the time of the inspection. The annual evaluation for 2023 was not signed nor dated.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In an effort to address citation 709.26 (b) (3), the following will be implemented:
Beginning on 12/28/2023, the HR Generalist will ensure that all annual evaluations are signed and dated by the supervisor and staff member prior to filing it in the employees record. In addition, the HR Generalist will train all supervisors across the organization on the procedures for signing and dating annual evaluations prior to submitting it to the HR Generalist.
The Executive Director will monitor the progress of this action step during monthly supervision with the HR Generalist. |