INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on April 27, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Open Door Counseling at Mazzoni Center 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 records, the facility failed to ensure that an annual written individual performance evaluation was completed for each employee in one of seven employee records reviewed.
Employee # 1 was hired as the project director on June 9, 2003. There was no documentation that an annual written individual performance evaluation was completed and signed by the employee for the the 2020 year as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Discussed issue with Executive Medical Officer on 5/3/21. EMO is aware of the need to document written review of performance evaluation for project director. EMO will ensure written documentation of performance is completed annually and submitted to HR. HR will monitor on an on-going basis. |