INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on February 16, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Genesis House (Bloomsburg) 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of personnel records, it was determined that the facility failed to ensure that staff members completed a feedback form on all training attended in one of two personnel records.
The findings include:
Based on review of three personnel records on February 16, 2012, the facility failed to document feedback forms from trainings received for employee #1 for the training year of 01/01/2011 through 12/31/2011. No feedback forms were included in personnel file #1 for that training year.
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Plan of Correction
Facility Director will review with all facility staff training requirements and procedures by 3/31/12. Facility Director will monitor training evaluation completion by requiring the certificate to be attached to the evaluation. The certificate of completion will not be accepted without the training evaluation. A review of the staff charts will be done quarterly to ensure compliance. |
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 records and an interview with the project director, the facility failed to document annual performance evaluations as required by agency policy and regulation in one of three personnel records.
The findings include:
Three personnel records were reviewed on February 16, 2012. All three personnel records were required to include documentation of annual performance evaluations. Per agency policy, performance evaluations are conducted at three months, six months and annually thereafter. There were no six month performance evaluations documented in personnel records #1.
Employee #1 was hired 04/04/2011 and required by policy to have an evaluation completed by 10/04/2011.
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Plan of Correction
Project Director will create a spreadsheet notifying management when annual reviews are to be completed. Project Director will expect receipt of review from management and employee within 30 days of notification. Project Director will mark completed on the spreadsheet when the review is received and notify management if the review is not received within 30 days. Project Director will review with all management the personnel management policy by 3/31/12. |