INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26-27, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mercy Behavioral Health 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 a review of personnel and training records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one personnel records.
The findings include:
The facility training year is from July 1 through June 30.
A review of personnel and training records was conducted on September 16-17, 2013. One personnel record pertained to the project director and was required to include documentation of at least 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 was hired at the project in June 1995 and has been the project director since October 2011. The facility failed to ensure that employee # 1 had documentation of 12 clock hours of training from July 2012 - June 2013 as only 6 hours of training were documented for that time frame.
The findings were discussed and confirmed with the facility director on September 17, 2013.
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Plan of Correction
Requirements for the Project Director to complete 12 clock hours of annual training was reviewed with the Project Director by the Faclility Director on October 10, 2013. For training year July 2013 through June 2014 Project Director will complete 12 clock hours of training. Facility Director will monitor for compliance with this standard. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of facility documentation, the facility failed to complete an annual report for 2012.
The findings included:
The facility's administrative documentation was reviewed on September 16-17, 2013. An annual report for 2012 was requested. The facility failed to document an annual report for 2012.
The findings were discussed and confirmed with the facility director on September 17, 2013. The findings were not disputed.
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Plan of Correction
Facility Director reviewed standard with Project Director (Executive Director)requiring an annual report for the project. A plan has been developed with the Executive Director and the internal Corporate Communications Manager to ensure that an annual report will be developed and distributed on an annual basis. Plans developed to complete 2013 Annual Report following the close of 2013. |