INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Summit Academy 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 administrative information, the facility failed to collect feedback on completed trainings in eight of eight applicable personnel records.
Facility policy and procedures state that feedback forms are to be completed after each training.
The training year beginning January 1, 2023, through December 31, 2023 was reviewed and feedback was not collected for any training.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Summit Academy will utilize a training evaluation form to collect feedback on completed trainings by staff moving forward. Forms will be distributed at the conclusion of training by the Clinical Coordinator or designee and collected by the Clinical Coordinator or designee immediately after. Evaluations will be submitted to Human Resources within 1 business day following the training and maintained in the personnel files. The Clinical Coordinator will be responsible for monitoring this. |