INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on May 3, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation, Inc., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiency was identified during this inspection.
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Plan of Correction
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, the facility failed to document written job descriptions which contained the employee's and supervisor's dated signatures in two of four personnel records.
The findings include:
Four personnel records were reviewed on May 3, 2012. Four personnel records were reviewed for documentation of a signed job description. The facility did not document a signed job description in personnel records # 2 and 3.
Personnel record # 2 pertained to a counselor with a documented hire date of 7/27/2011. An initial job description was signed by the employee on 7/26/2011. There was no documented signature of the supervisor.
Personnel record # 3 pertained to a counselor with a documented hire date of 03/19/2012. An initial job description was signed by the employee on 03/13/2012. There was no documented signature of the supervisor.
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Plan of Correction
The personnel files of all agency staff will be reviewed by Facility Director and HR Director by 6/15/2012 to ensure that all job descriptions have been signed by both the employee and supervisor. The HR Director will audit a sample of personnel files on a quarterly basis to ensure compliance with facility policies. Results of quarterly audits will be reported monthly to the Performance Improvement Committee. |