INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2023 staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Brighter Visions Counseling 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 the facility's staff development program the annual assessment is to be completed via anonymous questionnaire and subsequent group discussion by stakeholders. During the administrative review the facility failed to document an annual assessment of the staff training needs for the training year of January 1, 2023 through December 31, 2023. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
To correct this deficiency, a questionnaire will be provided to each staff member by December 10 for their input into the training plan to be collected by December 20. This questionnaire will be developed, circulated, and collected by the Facility Director. A plan of training will then be developed by January 1. This plan has been launched for completion by January 1, 2024. The application of this plan of correction is the responsibility of the Director. |
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 facility ' s staff development program, the annual training plan is to be developed January 1 of each year. During the administrative review the facility failed to document an overall plan for addressing staff training needs for the training year of January 1, 2023 through December 31, 2023. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Brighter Visions Counseling acknowledges and pledges compliance with §704.11 (c)(1)(2). Each year an overall training plan shall be developed with staff input by January 1 for that year. This plan shall be developed and documented by the Director. This POC is in place as of January 1, 2024. The Director is responsible for this implementation.
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