INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on December 2, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Gaudenzia Erie, Inc - Daniel Snow House 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of one personnel record.
The findings include:
Personnel records were reviewed on November 28-29, 2011. One personnel record reviewed was that of the clinical supervisor. This personnel record required the documentation of monthly meetings between the clinical supervisor and their supervisor for the first six months of employment in that position. The facility failed to document monthly supervision meetings in personnel record # 2.
Employee # 2 was hired at the project on May 3, 2004 and was promoted to the position of clinical supervisor on December 26, 2010. Monthly supervision meetings were required to take place in January, February, March, April, May and June 2011. There was no documentation of monthly supervision meetings in the personnel record of employee # 2.
An interview with the facility director took place on November 29, 2011 at which time it was confirmed that there was no documentation of monthly supervision meetings.
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Plan of Correction
New Clinical Supervisors, when hired, will receive monthly supervision meetings. These meetings will be documented and placed in their personnel files for their first six months of employment. Division or Program Director will complete these meetings. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document a written job description for the position of facility director, which contained the employee's and supervisor's dated signatures in one of one personnel record.
The findings include:
One personnel record for the facility director was reviewed on December 2, 2011. This record required documentation of a signed job description. The facility did not document a signed job description for the position of facility director in personnel record #9.
Employee #9 is the Director of Finance and Operations and was hired on September 16, 1996. The previous facility director resigned on November 11, 2011. Per the Staffing Requirements Facility Summary Report, employee #9 assumed the duties of facility director as of November 11, 2011. There was no documentation of a signed job description for the position of facility director in personnel record #9.
The facility director was interviewed on December 2, 2011. It was confirmed that there was no signed job description in place which included the duties of facility director.
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Plan of Correction
A signed job description has placed in the "Interim" Facility Directors personnel file. Regional Director along with the Director of Finance & Operations (In charge of HR in Erie) will monitor employee files to ensure correct job descriptions are in the employee files. |