INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on September 15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Horizon House, 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 supervisory review and a plan of correction is due on February 23, 2011.
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Plan of Correction
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a supervisory review of the licensing packet, the facility failed to ensure that the Project Director completed at least 12 clock hours of training during the 2009 training year.
The findings include:
On September 14 and 15, 2010 the Project Director's personnel record was reviewed for documentation of the completion of 12 clock hours of training as per the regulatory requirement. The Licensing Specialist indicated that there were no documented hours of training in the personnel record for the 2009 training year.
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Plan of Correction
Effective immediately, the CEO's Executive Assistant will ensure that all trainings/seminars attended by the CEO are submitted to the Organizational and Employee Development Department and documented in his training record. The QI Director will conduct semi-annual reviews of the CEO's training records to ensure that the trainings are being documented. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a supervisory review of the licensing packet, and an interview with the Licensing Specialist, the Project Director failed to annually update a written manual delineating project policies and procedures.
The findings include:
The Licensing Specialist indicated that the facility last updated the manual delineating the project policies and procedures on 11/29/2007.
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Plan of Correction
Effective immediately, the policy and procedure manual will be reviewed and updated annually and reflected on a cover-sheet sign-off by the Project Director. The QI Director will ensure that the Project Director reviews the policy and procedure manual and signs the cover page indicating their approval on an annual basis. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a supervisory review of the licensing packet, the facility failed to include salary information in one of five personnel records reviewed.
The findings include:
On September 14 and 15, 2010, five personnel records were reviewed for documentation of salary information. One out of five records reviewed, specifically the Project Director's personnel record, lacked documentation of the salary information.
The Licensing Specialist indicated that there was no documentation of the information in the Project Director's personnel record.
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Plan of Correction
During the licensing inspection in September 2010, a partial Project Director personnel record (for the CEO) was presented to the Licensing Specialist for review. The section that was presented for review did not have the salary information as specified in the regulation. For all future DDAPL licensing inspections, the HR Manager will ensure that the salary information for the CEO is included in the personnel file that is presented to the licensing specialist. |
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 supervisory review of the licensing packet, the facility failed to include an annual work performance evaluation in one of four personnel records reviewed.
The findings include:
On September 14 and 15, 2010, four personnel records were reviewed for documentation of an annual work performance evaluation. One out of four records reviewed, specifically the Project Director's personnel record, lacked documentation of an annual work performance evaluation.
The Licensing Specialist indicated that there was no documentation of an annual work performance evaluation in the Project Director's personnel record.
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Plan of Correction
An annual performance evaluation will be completed for the Project Director (CEO) by 4/15/11. Going forward, the Board Chair will ensure that the CEO has an annual evaluation by April 15th of each year. The QI Director will provide oversight to ensure that the CEO's annual performance evaluation is completed by April 15th of each year. |
709.26(d)(5)(ii) 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:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Based on a supervisory review of the licensing packet, the facility failed to include an annual work performance evaluation in one of four personnel records reviewed.
The findings include:
On September 14 and 15, 2010, four personnel records were reviewed for documentation of a written copy of an annual work performance evaluation. One out of four records reviewed, specifically the Project Director's personnel record, lacked documentation of a written copy of an annual work performance evaluation.
The Licensing Specialist indicated that there was no documentation of a written copy of an annual work performance evaluation in the Project Director's personnel record.
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Plan of Correction
(Duplicate to 0227)
An annual performance evaluation will be completed for the Project Director (CEO) by 4/15/11. Going forward, the Board Chair will ensure that the CEO has an annual evaluation by April 15th of each year. The QI Director will provide oversight to ensure that the CEO's annual performance evaluation is completed by April 15th of each year. |