INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on February 25-27, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Carbon Monroe Pike Drug and Alcohol Commission , 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of employee records, the project director failed to document the required minimum 12 hours of training for the 2011-12 training year.
The finding includes:
The annual onsite licensing inspection was conducted February 25-27, 2013. The project and facility director's employee training records were reviewed for the training year which ran from May 1, 2011 to April 30, 2012.
Employee training record # 1- This employee was hired on 1/1/88. The training record documentation for the training year ended 4/30/12 consisted of only 6 hours of annual training for this employee, not the minimum 12 hours required.
The finding was reviewed with the facility director and was not disputed.
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Plan of Correction
704.11 (d)(2) Annual Training Requirements:
The Executive Director (Project Director) has reviewed the requirements for training for the Project and Facility Director and will assure that at least 12 credits of training per training calendar year are obtained in accordance with this standard.
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709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of employee records , the facility failed to document an annual performance evaluation in two of five employee records.
The finding includes:
The annual onsite licensing inspection was conducted February 25-27, 2013. Two employee records failed to include documentation of an annual performance evaluation.
Employee record # 1 - The employee was hired on January 1, 1988. The last documented performance evaluation in this record was dated 1/25/11. There was no documentation of a 2012 or 2013 performance evaluation as of February 27, 2013.
Employee record # 3- This employee was hired on 6/15/95. The last documented performance evaluation in the employee record was dated 9/27/11. There was no documentation of an annual performance evaluation for 2012 as of February 27, 2013.
The finding was reviewed with the facility director and was not disputed.
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Plan of Correction
709.26 (d)(5)(i) Personnel Management:
At the 3/19/13 board meeting the Executive Director (Project Director) will discuss with the board membership the need to complete the required yearly evaluations in a timely manner to comply with this standard. Documentation will be recorded in board minutes. All delinquent evaluations noted will be completed and on the Personnel Records by April 19, 2013.
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