INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 22 through 23, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Namaan 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 and a plan of correction is due on August 20, 2008.
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Plan of Correction
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a July 22 through 23, 2008 review of facility records, the facility failed to conduct fire drills in three of eight months, specifically January, February and April.
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Plan of Correction
The Executive Director will see to it that fire drills are conducted at least once each month from this point forward. This issue will be corrected by 8/31/08. The Executive Director will either designate a staff person to conduct this fire drill or he will himself conduct the drill each month and ensure that it be done monthly. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a July 22 through 24, 2008 review of facility records, the facility failed to make the 2006-2007 annual report available to the public.
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Plan of Correction
The Executive Director will see to it that the annual report henceforth will be made available to the public and will so be documented. This issue will be corrected by 08/31/08. |
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 July 22 through 23, 2008 review of three employee records, the facility failed to document a performance evaluation in two of three employee records where needed, specifically employee records # 3 and 5. The annual performance evaluation for employee # 3 was eight months late and the probationary performance evaluation for employee # 5 was five months late.
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Plan of Correction
The Executive Director has conducted the annual performance evaluation for employee #3 already and the Executive Director has conducted the probationary performance evaluation for employee #5 already. The issue of having these type of evaluations conducted on time for the future will be corrected by 08/31/2008, by which time all supervisors would have been informed and trained, that such evaluations will have to be conducted in a timely manner. The Executive Director will handle this training and monitor this matter on an ongoing basis to ensure timely reviews. |