INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Retreat at White Birch 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(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 personnel records, the facility failed to provide documentation of individual training plans in one of two personnel records reviewed.The findings included:Two personnel records requiring documentation of individual training plans were reviewed on 10/21/2015. The facility failed to provide documentation of individual training plans for the current training year of 1/1/2015 - 12/31/2015 in personnel record # 2.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 was hired as a counselor and was not given an individual training plan for the current year 1/1/2015 - 12/31/2015. Therefore a signed copy of of the individual training plan was not entered into personnel record #2.
Employee # 2 shall be given an individual training plan for the current year for signature and date and will be entered into personnel file #2.
To prevent reoccurrence of this deficiency, the quality assurance coordinator will include individual training plans in all personnel records for dates and signatures, and all personnel records will be reviewed by the quality assurance coordinator and the Executive Director bi-annually. |