INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on June 12, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Public Health Management Corporation d/b/a PHMC Pathways to Recovery 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of personnel records, the facility failed to ensure that one of five applicable staff persons received a minimum of 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum within the regulatory timeframe.
Employee #3 was hired as a counselor on September 4, 2018 and was due to have TB/STD training no later than September 4, 2019. There was no documented training until November 15, 2019.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program will register new staff for mandatory trainings that are scheduled for within the first 6 months of employment. This will ensure attendance within the timeframe and build in a buffer period in case of absences.
Program Director and Clinical Director will oversee to confirm registration and attendance. |
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 the review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in two of four applicable personnel records.
Employee #1 was hired as the project director and facility director on January 8, 2018. There was no annual performance evaluation in the personnel record.
Employee #2 was hired as a clinical supervisor on January 2, 2019. The most recent performance evaluation was completed on June 30, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Performance evaluations will be completed for the outstanding evaluations before 7/1/2020. Ongoing, the Human Resources department of PHMC will work with leadership to ensure all evaluations are completely annually in a timely manner. |