INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mission New Life 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)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of agency training files the facility failed to comply with this regulation. No documentation was available of the assessment of staff training needs for the current training year.
The findings include:
Two personnel records were reviewed on August 10, 2011. Two of two personnel records required an assessment of staff training needs. Personnel record # 1 and 2 failed to include documentation pertaining to the assessment of staff training needs.
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Plan of Correction
Mission New Life will develop and implement a facility training needs assessment form which shall be used yearly to assess the staff's training needs for the upcoming calendar year. The new form shall be created by August 31, 2011 and completed by staff by September 15, 2011. The office manager will be responsible for providing yearly staff training needs assessment forms to all staff no later than December 31 of each calendar year. An individual training plan will be developed with staff according to their identified needs. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
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 four personnel records and discussion with the facility director it was determined that the facility failed to ensure that staff members completed a feedback form on all training attended.
The findings include:
Two personnel records required feedback on the staff development program on completed training. Two of two personnel records failed to include a method of feedback on completed training plans.
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Plan of Correction
Effective immediately the office manager shall ensure that training evaluations be completed by all staff for training attended by the employee. The office manager shall be responsible for auditing personnel files to ensure all trainings attended have a subsequent evaluation completed immediately after attending the said training. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on August 10, 2011. The facility did not document any alternate exit used during fire drills from June 1, 2010 through August 2, 2011. The main stair case was the exit route used during every fire drill.
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Plan of Correction
Effective immediately the clinical director shall be responsible for conducting monthly unannounced fire drills, for ensuring alternate exits are used, and documenting said fire drills. The office manager will be responsible for auditing the fire drill log to ensure that alternate exits are documented. The facility director will continue to monitor this standard to ensure continued compliance in this area. |
709.26(a)(10) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(10) Work performance evaluations.
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Observations
Based on a review of the agency policy and procedure manual , a sample of personnel records from the facility, and interviews with the Facility Director and the administrative assistant responsible for maintaining the personnel records, the facility failed to document annual work performance evaluations in adherence to written agency policy.
The findings included;
The agency policy and procedure manual was reviewed on August 10, 2011.
During the inspection the personnel records of the facility Director and one clinical staff were reviewed. Two of two staff did failed to i include an annual performance evaluation documented in compliance with written agency policy:
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Plan of Correction
Performance evaluation shall be conducted on an annual basis for all staff associated with Mission New Life. The facility director shall be responsible for evaluating the clinical directors, the office manager, and the billing agent, the clinical director shall be responsible for evaluating the clinical staff, and the office manager shall be responsible for evaluating all support staff. Initial evaluation shall be completed for all staff by October 31, 2011 and annually (date of hire anniversary date) thereafter. The Facility Director shall continue to monitor this area to ensure continued compliance of this standard. |