INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29 - 30, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Counseling Center of Mercer County 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 and a plan of correction is due on December 24, 2010.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the clinical supervisor and the Quality Assurance/Compliance Coordinator, the facility documented an overall plan for addressing training needs, as required by regulation, but did not include a date of completion.
The findings include:
On November 29, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, a training plan will be completed by June 30 of each training year. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility documented an overall training plan for the July 1, 2010 - June 30, 2011, but the plan was not signed and did not include a date of completion.
This was discussed with the clinical supervisor and the Quality Assurance/Compliance Coordinator on November 29, 2010. The clinical supervisor and the Quality Assurance/Compliance Coordinator confirmed that a plan for addressing training needs of staff was not dated, and therefore it could not be determined if the plan was completed in accordance with the facility policy and procedure.
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Plan of Correction
A signature line and date has been added to the templet to prompt the person completing the plan to add a signature and date of completion. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual and an interview with the clinical supervisor and the Quality Assurance/Compliance Coordinator, the facility failed to document an annual evaluation of the overall training plan which included a date of completion.
The findings include:
On November 29, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an annual evaluation of the training plan will be completed by July 31. The regulation requires an annual evaluation of the overall training plan to be completed as a component of a staff development program. The facility documented the completion of an annual evaluation of the overall training plan for the July 1, 2009 - June 30, 2010 training year, but the annual evaluation was not signed and did not include a completion date.
This was discussed with the clinical supervisor and the Quality Assurance/Compliance Coordinator on November 29, 2010. The clinical supervisor and the Quality Assurance/Compliance Coordinator confirmed that an annual evaluation of the overall training plan was not dated, and therefore it could not be determined if the annual evaluation was completed in accordance with facility policy and procedure.
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Plan of Correction
A signature line and date has been added to the templet to prompt the person completing the evaluation to add a signature and date of completion. |
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 review of administrative polices and procedures and an interview with the Quality Assurance/Compliance Coordinator, the facility failed to document that the project director completed an annual update of the written manual delineating project polices and procedures.
The findings include:
The administrative policies and procedures were reviewed on November 29, 2010. The project director failed to document the annual update of the written project policies and procedures, as required by regulation.
This was discussed with the Quality Assurance/Compliance Coordinator and the clinical supervisor on November 29, 2010. The facility director documented a review of the project polices and procedures via a dated signature, but the project director failed to document a review.
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Plan of Correction
A new signature page with the appropriate titles and dates has been added to the Policy and Procedure manual. |