INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21-22, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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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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
Fourteen personnel records were reviewed on July 21, 2016. Eight of the fourteen records reviewed required documentation of an annual written individual staff performance evaluation. The facility failed to document an annual written performance evaluation that had been signed by the employee for employee # 9.
Employee # 9 was hired on 4/14/15 and was promoted to the counselor position on 7/28/15. An annual written performance evaluation completed for the employee on 4/30/16 failed to document the employee's signature.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Assistant Facility Director will create a tracking sheet for all facility staff anniversary date to ensure all personnel reviews are conducted in a timely manner and that all staff and supervisor sign off on the annual reviews. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Ten client records were reviewed on July 21-22, 2016. The facility failed to obtain an informed and voluntary consent where consent was applicable in client record # 10.
Client # 10 was admitted into treatment on 11/30/15 and was discharged on 2/19/16. The client's record indicated that a letter regarding the client's pending discharge was faxed to the client's attorney on 1/29/16. A consent to release information to the attorney was not documented in the client's record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Clinical Director will conduct a staff training on the proper completion of consent to release information forms with all facility staff on 8/24/16.
Facility Director and Facility Clinical Director will conduct reviews of client charts to ensure that consent to release information forms are completed on all client documentation releases on a monthly basis which will occur during monthly chart audits. Monthly chart audit will occur during the first week of each month. |