INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 16, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Access and Services Center of Berks County, Inc. (TASC) 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
|
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill records, the facility failed to conduct a fire drill at least once a month.
The findings include:
A review of the facility's fire drill records was conducted on 12/16/2014. There was no documentation of an unannounced fire drill in July 2014.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Unannounced fire drills will be conducted on a monthly basis. The four TASC supervisors will alternate months of the calendar year and will be responsible for scheduling and facilitating each respective fire safety drill. A log of each fire drill will be compiled in an Excel spreadsheet saved in the Management Shared Documents file, and will include the date, time, number of staff and clients evacuated, duration, exit routes used, identification of full building or silent alarm, and any pertinent notes documenting the event. |
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, the facility failed to document an annual performance evaluation in two of three applicable personnel records reviewed.
The findings include:
Two personnel records requiring documentation of an annual performance evaluation were reviewed on 12/16/2014. The facility failed to document an annual performance evaluation in personnel records # 1 and 2.
Employee # 1 was hired as an evaluator on 8/25/2003. The employee did not have an annual performance evaluation in 2013.
Employee # 2 was hired as an evaluator on 6/30/2008. The employee did not have an annual performance evaluation in 2013.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
TASC supervisors will conduct annual performance evaluations for all TASC staff. The Executive Director will conduct annual performance evaluations on all TASC supervisors. All performance evaluations will be stored in each respective employee's confidential personnel file. An Excel spreadsheet will track each employee's anniversary date, and Microsoft Outlook will generate an electronic notification to each supervisor when annual evaluations are due for each respective employee or supervisor. All employee performance evaluations will be reviewed by the Executive Director, and reviewed with each employee and supervisor. |
709.42(e) LICENSURE Display of operation hours
709.42. Project management.
(e) The hours of operation shall be displayed conspicuously to the general public.
|
Observations
Based on a physical plant inspection, the facility failed to display the hours of operation to the general public.
The findings include:
A physical plant inspection was conducted on 12/16/2014. The facility's hours of operation were not displayed to the general public.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A multi-colored sign listing the hours of operation and telephone number for TASC was created and prominently displayed on the front doors of the main entrance in the building where TASC is located. The sign also denoted that TASC is closed on Saturdays and Sundays. The sign is easily and readily viewable by the general public. |
709.42(f) LICENSURE Display of Phone #
709.42. Project management.
(f) A telephone number shall be displayed conspicuously to the general public.
|
Observations
Based on a physical plant inspection, the facility failed to display a telephone number that can be accessed by the general public.
The findings include:
A physical plant inspection was conducted on 12/16/2014. A telephone number that is conspicuously displayed to the general public is required at all intake, evaluation and referral programs. The facility did not display a telephone number.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A multi-colored sign listing the hours of operation and telephone number for TASC was created and prominently displayed on the front doors of the main entrance in the building where TASC is located. The sign also denoted that TASC is closed on Saturdays and Sundays. The sign is easily and readily viewable by the general public. |