INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 30, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cora Services, 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 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
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in 1 of 4 records reviewed.
Employee #1 was hired as the project/facility director on 9/1/87 and was still in the positions. There was no documentation of a signed and dated annual work performance evaluation in the personnel record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CORA Services has revisited the procedures for annual performance evaluation of all eligible employees. The policy and procedures are correct and in compliance with standards, but in the months' long pending transition of project leadership, the evaluation of the current project director was overlooked. On 11/1/2017, a reminder system has been put in place for Human Resource and Administrative personnel for evaluation alerts one month prior to due date. |