INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Allied Addiction Recovery, LLC 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 staff records, the facility failed to ensure personnel records included an annual written individual staff performance evaluation in one of two records. Staff #3 was hired as a counselor on March 14, 2022 and is still in the position. Staff #3 was due to receive an annual written individual staff performance evaluation on March 14, 2024. Staff #3's record did not contain an annual written individual staff performance evaluation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director reviewed citation with Facility Director on 5/16/2024. Clinical Director will complete employee performance review by 5/23/2024. It will then be reviewed by Facility Director. Clinical Director will meet with employee to review and discuss the review. Upon completion of the EPR employee will have the opportunity to ask questions and sign the document. Copy of EPR will be given to employee. Clinical Director will have electronic calendar reminders set for each employee EPR date to alert Clinical and Facility Director of due dates 2 weeks prior to EPR needing to be completed. Clinical Director will also document all employee hire dates at beginning of the training year to be completed with yearly training plans. |