INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, T.W. Ponessa & Associates Counseling Services, 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(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 a review of the Staffing Requirements Facility Summary Report during presubmission and on-site July 7, 2016, the facility failed to provide documentation of HIV/AIDS and STD/TB training in one of seven applicable records reviewed.
Employee #7 was hired on June 23, 2014 as Support Staff and was required to obtain six hours of HIV/AIDS and four hours of STD/TB training by 6/23/2016. Employee #7 failed to obtain the training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the June 10, 2015 licensing inspection.
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Plan of Correction
Employee # 7 will complete 6 hours of HIV and 4 hours of TB/STD training by 9-1-16. The trainings will be conducted by the Facility Director using the DDAP approved training curriculum. Moving forward, the Facility Director will ensure that all non-clinical staff receive their required trainings within 2 years of their hire date. The Facility Director will develop a spreadsheet to track training requirements for staff and review it monthly to update and schedule required trainings for all applicable staff. |
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 on July 7, 2016, the facility failed to document an annual performance evaluation in three of six applicable personnel records.
Employee # 1 was hired as the CEO on August 10 2005. An annual performance evaluation was due to be completed by September 2015 and was not completed at the time of the inspection.
Employee # 2 was hired as the Drug & Alcohol Director July 10, 2010. An annual performance evaluation was to be completed by August 2015 and was not completed at the time of the inspection.
Employee # 3 was hired as the Clinical Supervisor on September 9, 2013. An annual performance evaluation was to be completed by October 2015 and was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee # 1(CEO) will have her annual performance review completed by the President of TW Ponessa Counseling Services, Inc. by 8-1-16.
Employee # 2 (D&A Director) will have her annual performance review completed by the Project Director(CEO) by 7-31-16. Employee # 3 (Clinical Supervisor) will have his annual performance review completed by the Facility Director(D&A Director)by 7-31-16. Moving forward, the Project Director will ensure that her performance review and the Facility Director's performance review are completed by August 1 of each year. The Facility Director will ensure that the performance review for the Clinical Supervisor is completed by August 1 of each year. |