INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Home Nursing Agency Community Services 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, the facility failed to document a mechanism to consistently collect feedback on completed training in two of six personnel records reviewed.The findings include: Six personnel records which required documentation of feedback on completed training were reviewed on June 25, 2015. The facility failed to consistently document the submission of completed feedback forms after the completion of employee training in personnel records # 2 and 4. Employee #2 has been in the facility director position since January 2009. The employee's personnel record failed to consistently document feedback on completed training. Employee #4 has been in the clinical supervisor position since April 2006. The employee's personnel record failed to consistently document feedback on completed training. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A monthly education tracking report will be distributed to the Clinical Services Manager who will take to a monthly staff meeting for review.
The Clinical Services Manager will assure all education is completed and all paperwork including the evaluation form for any continuing education is turned in together within 30 days of inservice.
Disciplinary action will be taken in the event information is not submitted or obtained per Procedures 6001 Education Plan for Staff.Diana Packech
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