INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Glenbeigh Center of Erie 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 written annual individual staff performance evaluations for 2020 in three of three personnel records reviewed on September 14, 2021.
There were no written 2020 staff performance evaluations documented in the following personnel records:
Employee # 1 was hired July 20, 2015.
Employee # 2 was hired December 14, 2015.
Employee # 3 was hired December 4, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will perform an annual performance evaluation on each employee each calendar year. On years where the organization as a whole does not complete performance evaluations, the project director shall perform performance evaluations for all Erie center employees. The project director shall also have an annual performance evaluation completed on him each calendar year by the director of operations. These evaluations will be stored in HR files and available to be accessed by auditors. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information within thirty days of discharge, per facility policy, in two of three client records reviewed on September 14, 2021.
No follow-up information was documented in the following client records:
Client # 4 was admitted May 11, 2021 and discharged July 28, 2021.
Client # 6 was admitted March 17, 2021 and discharged June 2, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An ongoing list of discharged clients will be made by the front office that states the date needed to contact the discharged client 30 days after discharge regardless of discharge status. A thirty day follow up will be completed and documented in the medical record by front office staff for every client regardless of discharge status 30 days after discharge. This will be monitored by both the office manager and project director. |