Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on July 9, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Interim House West, 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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Observations
Based on the review of personnel records, the facility failed to ensure that personnel records contained documentation of an annual written individual performance evaluation signed and reviewed by the employee in one of three applicable employee records reviewed.
Employee # 3 was hired as a counselor on November 1, 2004. The personnel records provided did not contain documentation of an annual performance evaluation for the July 1,2018 - June 30, 2019 review year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the review of personnel records, the facility failed to ensure that personnel records contained documentation of an annual written individual performance evaluation signed and review by the employee in one of three applicable employee records reviewed.
Due to the staff oversight, effective immediately the Clinical Director will complete employee #3 annual performance evaluation/ and going forward all staff annual performance evaluation will be completed within the designed time frame from their hire date. Program Director and Human Resource Department will monitor and follow the guidelines that are in placed to ensure that individual performance evaluation is sign and review by employee.
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