INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on January 24, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Treatment Treads Inc (Halfway 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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704.11(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 employee training records on January 24, 2012, the facility failed to provide each employee received a written individual training plan in one of four personnel records.The findings include:On January 24, 2012, a review of four personnel records revealed that the individual training plan was not completed for staff #1. The individual training plan was not documented for the 2010-2011 training year. The last documented individual training plan for staff #1 was November 2010.
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Plan of Correction
704.11. Staff development program.
In response to the deficiency of employee number one, within thirty days from this date the Chairman of the Board of Directors will complete an evaluation of Employee #1. This will be done annually from here forward.
In response to the deficiency, the Chairman of the Board has been informed of the licensing requirements of BDAP and will adhere to them.
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, the facility failed to maintain the structure in a free from danger and safety condition.The findings include:Four floors of the half-way house were inspected on January 24, 2012. The stairs leading from the first to the second floor of the women's side of the house had two steps that had carpet pulled away, creating a gap that provided a safety concern for anyone using the stairs.
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Plan of Correction
705.2. Building exterior and grounds.
The carpet on one of our staircases in the Annex was worn. Staff removed some of the excess carpet and placed tape over the area to eliminate the immediate safety hazard. The carpet has been ordered and will be installed by the maintenance department within 30 days. The Program Director will insure that the work is completed within this time frame. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation and a physical plant inspection, the facility failed to provide paper towels or a mechanical dryer in each bathroom. The findings include:A physical plant inspection was completed on January 24, 2012. There was no evidence of paper towels or mechanical dryer in the female bathroom. The physical plant manager confirmed the finding. Paper towels or mechanical dryer were not in the above referenced bathroom.
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Plan of Correction
705.6. Bathrooms. The facility has multiple hand towel dispensers throughout the facility and one was empty at time of the inspection.
As a corrective action to this defiency, within one week of this plan being submitted, the House Manager will insure that all the machines are filled on a daily basis and that there is a minimum of two extra rolls of hand towels in each bathroom at all times. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel files and administrative policies and procedures the facility failed to meet the requirements of this regulation as evidenced by the absence of annual performance reviews in 1 of 4 records.The findings include:Based on the review of four personnel files on January 24, 2012, the facility failed to include an annual individual staff performance in file 1#. Staff personnel #1 was hired in 1983. The last documented annual performance was completed in November 2010.
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Plan of Correction
704.11. Staff development program.
In response to the deficiency, within thirty days from this date the Chairman of the Board of Directors will complete an evaluation of Employee #1. This will be done annually from here forward.
In response to the deficiency, the Chairman of the Board has been informed of the licensing requirements of BDAP and will adhere to them.
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