INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 31, 2010 and September 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harbor Counseling 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 and a plan of correction is due on September 30, 2010.
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Plan of Correction
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704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of facility policy and procedure and an interview with the facility director, the facility failed to document an assessment of staff training needs.
The findings include:
On August 31, 2010 facility policy and procedure relating to staff training was reviewed. The Facility policy and procedure requires that each employee will have training needs assessed by July annually. The facility training year is from July through June annually. The regulation requires an assessment of staff training needs to be completed as a component of a staff development program. The facility failed to document the completion of a staff training needs assessment in July of 2010 for the 2010/2011 training year.
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Plan of Correction
Facility Director will conduct and document an assessment of staff training needs by 9/30/2010. The assessment will be submitted to the organization's Board of Directors at the 10/4/2010 meeting of the Board. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the project/facility director, the facility failed to document an overall plan for addressing training needs, as required by regulation.
The findings include:
On August 31, 2010 facility policy and procedure regarding staff training was reviewed. Facility policy and procedures require a training plan will be completed after the summary of staff training needs. The regulation requires an overall plan for addressing training needs to be completed as a component of a staff development program. The facility failed to document the completion of an overall training plan.
The project/facility director was interviewed on August 20, 2010 at approximately 1:30 PM. The project/facility director confirmed that a plan for 2010/2011 addressing training needs of staff was not completed.
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Plan of Correction
Facility Director will complete and document an overall training plan to address staff training needs by 9/30/2010. The staff training plan will be submitted to the organization's Board of Directors at the 10/4/2010 meeting of the Board.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of facility policy and procedure relating to staff training and an interview with the project/facility director, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
On August 31, 2010 facility policy and procedure relative to staff training was reviewed. Facility policy and procedures required an annual review of the training plan be completed in July of each year. The facility training year is from July through June. The regulation requires an annual evaluation of the overall training plan to be completed as a component of a staff development program. The facility failed to document the completion of an annual evaluation of the overall training plan for the 2009/2010 training year.
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Plan of Correction
Facility Director will complete and document an evaluation of the 2009/2010 staff training plan by 9/30/2010. The training plan evaluation will be submitted to the organization's Board of Directors at the 10/4/2010 meeting of the Board.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of staff development records, the facility failed to provide documentation of individual training plans in five of five records reviewed.
The findings include:
Five staff development records were reviewed on August 31, 2010. Individual training plans were required in the five records. Agency policy requires individual training plans by July annually. The facility did not document individual training plans in personnel records # 1, 2, 3, 4, and 5.
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Plan of Correction
Facility Director will develop and document individual training plans for all agency staff by 9/30/2010. The training plans will be submitted to the organization's Board of Directors at the 10/4/2010 meeting of the Board, and the individual staff development plans will be included in the appropriate personnel records.
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