INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 19-21, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility's policy and procedure manual in one of three applicable records reviewed.
The facility's policy and procedure manual states the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 28 each year.
Employee #3 was hired on February 4, 2007 and promoted to clinical supervisor on September 11, 2023 and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until July 2, 2024.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Human Resources identifies and sends an email each year notifying all supervisors when evaluations are released for completion. Supervisor will complete all evaluations and review with staff. Staff evaluations will be completed by the Supervisor and reviewed with staff by 2/28/2024. Division Director will request a report of any outstanding evaluations. Any deficiencies will be addressed within 48 hours. |