INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 3, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pathway Services, 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one personnel records.The findings include:Three personnel records were reviewed on February 3, 2016. One personnel record pertained to the project director required the documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.Employee # 1 has been the project director since December 1, 2005. The facility training year is from September through September. The facility documented that employee # 1 had 9 hours of training for the September 2014 - September 2015 training year.
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Plan of Correction
The Project Director will have 12 clock hours of annual training along with the required documentation for the facility training year September 2015 through September 2016 and for each additional training year thereafter. The 12 clock hours of annual training required documentation will be placed in the annual training personnel record #1. The owner of the facility will take the necessary steps to ensure that the project director has 12 clock hours of annual training every training year therefore preventing this deficiency from recurring. |
709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on a review of administrative documentation, the facility failed to comply with the directive issued by the Department requiring the facility to develop and implement policies and procedures for the reporting of unusual incidents. The findings include:As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents. The facility's administrative records were reviewed for documentation of policies and procedures for the reporting of unusual incidents on February 3, 2016. As of the date of the inspection, the facility has not developed policies and procedures for the reporting of unusual incidents.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 2/10/2016 the facility has implemented the Unusual Incident Policy and Procedure and it has been included in the facility's administrative records. The Project Director will be responsible for making sure that the corrective action is taken and stays implemented. |