INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 22, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Familylinks, 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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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on an onsite inspection on June 22, 2011, the facility failed to have all fire extinguishers
inspected annually. One of three fire extinguishers had not been inspected since July 2004.
The findings include:
Based on an onsite inspection conducted on June 22, 2011, the facility had three fire extinguishers in the facility and one had not been inspected annually. The fire extinguisher was located at the end of the hall and was not mounted but was sitting on the floor. The date of the last inspection was in 2004. The gauge indicated the extinguisher was still in active use. The location of this extinguisher was beside the day care room which posed an immediate hazard to the children in the day care room.
A conversation with the Senior Program Manager at 4:00 P.M., confirmed the fire extinguisher was on the floor and had not been inspected since 2004.
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Plan of Correction
The fire extinguisher that was left on the floor in the hallway was an old extinguisher that is not in use anymore. It had been in a storage area and had been inadvertently placed in the hallway instead of being disposed of. On June 22, 2011 the program manager immediately called the maintenance department and had them remove the exit extinguisher that day. Beginning August 1, 2011 all fire extinguishers will be monitored by utilizing the health and safety checklist t which is completed monthly and reviewed during the monthly agency health and safety meeting.
Completion date: 8/1/2011 and then monthly
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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.
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Observations
Based on a review of four personnel records, a review of the facilities policy manual, and an interview with the Senior Program Manager on June 20,2011, the facility failed to have a signed work performance evaluation in one of four employee records.
The findings include:
Four employee records were reviewed on June 20, 2011. The facility failed to document an annual performance evaluation in one of the employee records.
Employee record # 1 failed to include documentation of an annual staff performance evaluation. Employee record #1 represented the CEO of the facility. Project policy stipulated that the evaluation of the CEO would be completed by the Executive Board. There was no documentation in the employee record or in the board meeting minutes demonstrating that the evaluation had been completed.
On June 21 2011, the CEO presented a performance evaluation dated October 21, 2010, however, the board failed to sign the evaluation until June 21, 2011.
An interview with the Project Director, Senior Program Director and Human Resource Department confirmed the last evaluation completed by the board for employee # 1 was documented for January 29, 2009.
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Plan of Correction
A new CEO (Project Director) evaluation process was developed by the Familylinks Board of Directors in April 2011. On June 2nd, 2011, a CEO Support Committee was formed as part of this process. One of the tasks this Committee is charged with is the completion of the CEO's annual evaluation. The Board of Directors will create and or amend, and approve all performance goals for the CEO and they are then given to the CEO Support Committee. As part of the Committee's evaluation process, an independent contractor has been retained to complete a 360 evaluation of the CEO. The CEO Support Committee will evaluate the CEO based on his performance on the Board established goals in conjunction with the 360 evaluation. The CEO's annual evaluation will be completed each year at the beginning of the fiscal year. The current evaluation will be completed by 8.31.11 |