INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection Cora 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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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 files, the facility failed to ensure annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, were completed in one of three applicable personnel records reviewed.
Employee #1 was hired as the facility director on August 1, 2021. There was no documentation that an annual written individual performance evaluation was completed for the 20022 year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CORA Services has revisited the procedures for annual performance evaluation of all eligible staff. The policy and procedures are in compliance with standards, but due to the transition of project leadership, the evaluation of the facility director was missed in error. On 11/17/2023, a reminder system has been put in place for Human Resource and Administrative personnel for individual performance evaluations one month prior to due date. Employee #1 will receive an individual performance evaluation by their direct supervisor on or before 12/7/23. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 60 days in three of seven client records reviewed.
Client # 4 was admitted November 4, 2021 and was discharged October 1, 2023. A treatment plan update was completed on May 9, 2023 and the next update was due no later than July 9, 2023; however, the update was not completed until September 1, 2023.
Client # 6 was admitted October 6, 2022 and was discharged July 31, 2023. A treatment plan update was completed on April 18, 2023 and the next update was due no later than June 18, 2023; however, the update was not completed prior to discharge.
Client # 7 was admitted November 11, 2022 and was discharged May 1, 2023. A treatment plan update was completed on January 21, 2023 and the next update was due no later than March 21, 2023; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff were provided with additional training on procedures for the review of treatment and rehabilitative plans.
Additionally, the clinical supervisor will review all treatment plans for the entire client base on a monthly basis to ensure that plans are reviewed every 60 days.
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