INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on March 8, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Empowerment Resurrection 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.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of copies of staff CPR and First Aid cards, staff schedules, and a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that CPR and First Aid certification was provided to a sufficient number of staff persons, so that at least one person trained in these skills was onsite during the project's hours of operation.
The findings include:
The facility's posted hours of operation are Monday through Thursday 9 AM - 2 PM with evenings by appointment 5 PM to 9 PM as per work schedules and policy and procedures.
On March 8, 2013, copies of staff CPR and First Aid cards, staff schedules, and the facility's Staffing Requirements Facility Summary Report as provided by the facility on 3/8/13 were reviewed.
The facility had an insufficient number of staff persons trained in CPR and First Aid during the project's hours of operation.
Employee # 1, the Project Director was hired 2/15/13.
A review of employee # 1's certification revealed that he was the only staff person with CPR certification; however, he did not have documentation of First Aid certification.
Employee # 2, a counselor was hired 2/15/13.
Employee # 2 was not certified in CPR or First Aid.
Employee # 3, a counselor was hired 10/4/12.
Employee # 3 was not certified in CPR or First Aid.
There was no one certified in CPR during the evening hours on February 20 and 27, 2013.
There was no one certified in CPR during the evening hours on March 6, 2013.
There was no one certified in First Aid during the evening hours on February 19, 20, 21, 26, 27, and 28, 2013.
There was no one certified in First Aid during the evening hours on March 5, 6, and 7, 2013.
In addition, two volunteers work Monday through Thursday 9 AM - 2 PM neither of the volunteers were CPR or First Aid certified. Therefore there was no one certified in CPR or First Aid on February 19, 20, 21, 25, 26, 27, and 28, 2013 from 9 AM - 2 PM.
There was no one certified in CPR or First Aid on March 4, 5, 6, and 7, 2013 from 9 AM - 2 PM.
The Project Director confirmed the findings.
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Plan of Correction
Documentation of the Program Director's First Aid certification is now in his personnel file along with the documentation of his CPR certification. The two counselors and two volunteers will be trained in CPR and First Aid on April 20. A CPR trainer is coming to the ERC office on Saturday April 20 to train all staff and volunteers in CPR and First Aid. The Program Director will insure that copies of their certifications are put in the personnel files and that staff and volunteers are recertified as needed. Until April 20 when all staff are CPR and first aid certified, the Program Director will be on site while any clients are receiving services. No clients will be permitted in the office during the day. During the evening when counseling is scheduled, the Program Director will be in the office in case of medical emergency. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain a minimum of two exits that are separated by a minimum distance of 15 feet.
The findings include:
A physical plant inspection was conducted on March 8, 2013, at approximately 4 PM. The facility failed to maintain a minimum of two exits that are separated by a minimum distance of 15 feet.
It was observed that there was only one means of egress from the facility.
The Project Director confirmed during the physical plant inspection that the facility had only one entrance/exit.
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Plan of Correction
We have spoken to our landlord and begun arrangements to move to a location that has two fire exits. This move will take place before June 30, 2013. The board of directors and program manager are responsible for making sure this move occurs, and that any future move is to a location that meets the requirements for fire safety. |
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 review of the facility's fire drill log, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
On March 8, 2013, the facility's fire drill log was reviewed covering the period of November 2012 through February 2013. The facility failed to conduct fire drills during two out of four months.
The facility failed to conduct unannounced fire drills during the months of November 2012 and December 2012.
The Project Director confirmed the findings.
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Plan of Correction
Effective immediately, staff on all shifts will conduct unannounced fire drills monthly while clients are present. These drills will be documented on the fire drill log. The Program Director will be responsible for making sure the fire drills occur monthly |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the facility's fire drill log, the facility failed to conduct fire drills during normal staffing conditions.
The findings include:
On March 8, 2013, the facility's fire drill log was reviewed covering the period of November 2012 through February 2013. The facility documented two fire drills during this period. A fire drill was conducted on 1/11/13 at 10 AM and a fire drill was conducted on 2/12/13 at 8:45 AM.
The facility failed to conduct fire drills during normal staffing conditions.
The facility's posted hours of operation are Monday through Thursday 9 AM - 2 PM with evenings by appointment 5 PM to 9 PM as per work schedules and the policy and procedures manual.
At the time of inspection the facility did not offer day shift hours for counseling services, nor was any of the clinical staff present during this time.
The Project Director confirmed the findings as he stated the fire drills were being conducted by the volunteer staff during the day when neither clients nor staff were present.
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Plan of Correction
Counseling staff have been trained to conduct unannounced fire drills monthly during evening hours when clients are present. Effective immediately, these drills will be conducted and documented on the fire drill log. The Program Director is responsible for insuring that the fire drills occur during normal staffing conditions while clients are in the facility. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill log, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The findings include:
On March 8, 2013, the facility's fire drill log was reviewed covering the period of November 2012 through February 2013.
The facility provided a "Fire Drill Sheet" that was outlined with volunteer/staff name, date, time, and duration.
The "Fire Drill Sheet" failed to include the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
The Board Member and Project Director confirmed the findings.
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Plan of Correction
A new fire drill log has been created that includes the date, time, amount of time the evacuation took, the exit route used, the number of people present, any problems encountered, and whether the smoke detector or fire alarm worked properly. This log will be used for all fire drills beginning with April 2013. The Program Director is responsible for making sure that the corrected fire drill log is utilized. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's fire drill log, the facility failed to conduct fire drills on different times of the day and on different staffing shifts.
The findings include:
On March 8, 2013, the facility's fire drill log was reviewed covering the period of November 2012 through February 2013.
The facility failed to conduct fire drills on different staffing shifts as the facility only documented two drills during the time period reviewed and both drills were conducted during the day when only volunteer staff was present not during the facility's hours of operation in the evening on Monday through Thursday 6 PM to 9 PM.
The Project Director confirmed the findings.
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Plan of Correction
The Program Director has trained all staff to conduct fire drills on their shifts while clients are present. These fire drills will occur unannounced at different times of the day and on different days of the week. The Program Director is responsible for insuring that these drills occur on various days and times. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative documentation and financial records were reviewed on March 8, 2013.
The facility has an exception to the Department of Drug and Alcohol Program's General Standards for Free-Standing Treatment Activities, Chapter 709.25 (a), relative to an independent annual audit of financial activities associated with the project's drug/alcohol abuse services. However, the exception states: " In lieu of the annual audit, a certified public accountant will review the bank statements and complete the corporation's tax return. In addition, all financial reports including bank statements, payroll and staffing records and annual tax returns will be available for Division review during on-site licensing inspections."
The facility failed to provide documentation that a certified public accountant completed the corporation's tax return.
Neither the Board Member nor the Project Director disputed the findings.
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Plan of Correction
A Certified Public Accountant will complete ERc's taxes by May 6, 2013. In the future, the taxes will be completed by a CPA annually. The Program Director will insure that this occurs. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records and clinical documentation, the facility failed to document an informed and voluntary consent from the client for the disclosure of information in five of five client records reviewed.
The findings include:
Five client records requiring documentation of an informed and voluntary consent were reviewed on March 8, 2013. The facility did not document informed and voluntary consent for the release of information in five of five client records; client record # 1, 2, 3, 4, and 5.
The consent to release forms in the five of five records reviewed did not contain documentation of the client's right to verbally revoke a signed consent for the release of information. The facility documented that the client must revoke the consent in writing.
The Board Member and Project Director confirmed the findings.
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Plan of Correction
The informed and voluntary consent form has been revised to explain that the client may revoke their consent verbally. This revised form will be used effective immediately. Clients #1,2,3 ,4 5, will have the opportunity to review and sign the revised form informing them of their right to verbally revoke their prior consent to allow the release information. The Program Director is responsible for making sure that the revised informed and voluntary consent form is used and is filed in each client chart. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a psychosocial evaluation according to policy in four of five records reviewed.
The findings include:
The facility policy states: " The complete intake assessment includes the drug and alcohol use history, substance abuse treatment history, personal and psychosocial evaluation, family history, legal history, psychiatric history, and a preliminary treatment plan. The intake will be completed before the end of the first week of treatment and documented."
Five client records requiring documentation of a psychosocial evaluation were reviewed on March 8, 2013. The facility failed to document a psychosocial evaluation in accordance with facility policy in four of five records reviewed; in particular client record # 1, 2, 4, and 5.
Client # 1 was admitted to the program on 1/30/13 and was still an active client at the time of review on 3/8/13. The psychosocial evaluation was due before the end of the first week of treatment. The facility failed to document a psychosocial evaluation for client # 1.
Client # 2 was admitted to the program on 12/19/12 and was still an active client at the time of review on 3/8/13. The psychosocial evaluation was due before the end of the first week of treatment. The facility failed to document a psychosocial evaluation for client # 2.
Client # 4 was admitted to the program on 9/27/12. The facility documented a psychosocial evaluation; however the evaluation was not dated; therefore it could not be determined if it was documented before the end of the first week.
Client # 5 was admitted to the program on 1/31/13. The facility documented a psychosocial evaluation; however the evaluation was not dated; therefore it could not be determined if it was documented before the end of the first week.
The Project Director confirmed the findings.
This is a repeat citation. The facility was previously cited during the 3/28/12 inspection.
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Plan of Correction
The Program Director has trained the staff that all clients need a psychosocial evaluation after the psychosocial assessment is completed. The staff are aware that this must be completed before the end of the first week of treatment. Clients #1 and #2 now have a psychosocial assessment in their charts. The psychosocial evaluations for clients #4 and #5 are now dated. The Program Director is responsible for making sure that a psychosocial evaluation is completed and dated within the first week of treatment for each client. The Program Director will audit all client charts monthly to insure that documentation (such as the psychosocial evaluation) is completed according to policy. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to include support services on the individual treatment plan in three of five records reviewed.
The findings include:
The facility policy states: "The treatment plan shall include the following elements: short and long-term goals for treatment as formulated by the client and the counselor. The goals should follow the SMART format (specific, measurable, attainable, realistic, time-limited). Type and frequency of individual and group sessions and other treatment services. Type of support services (psychological counseling, psychiatric services, educational services etc.)"
Five client records requiring documentation of support services on the individual treatment plan were reviewed on March 8, 2013. The facility failed to document support services on the individual treatment plan in three of five records reviewed; in particular client record # 1, 2, and 4.
Client # 1 was admitted to the program on 1/30/13. The individual treatment plan was documented on 1/30/13; however the plan failed to include a proposed type of support service.
Client # 2 was admitted to the program on 12/19/12. The individual treatment plan was documented on 12/19/12; however the plan failed to include a proposed type of support service.
Client # 4 was admitted to the program on 9/27/12. The individual treatment plan was documented on 10/25/12; however the plan failed to include a proposed type of support service.
The Project Director confirmed the findings.
This is a repeat citation. The facility was previously cited during the 3/28/12 inspection.
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Plan of Correction
The Program Director has trained the staff on the necessity of identifying support services on every treatment plan. Clients #1, #2, and #4 now have support services added to their treatment plans. The Program Director is responsible for reviewing all treatment plans to insure that support services have been listed. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a treatment and rehabilitation plan update every 60 days in two of four records reviewed.
The findings include:
The facility policy states: "The treatment team will meet with a client to review the treatment plan every 60 days. At this time, the progress on the stated goals, strategies or action steps will be reviewed/revised."
Four client records requiring documentation of a treatment plan update were reviewed on March 8, 2013. The facility failed to document a treatment plan update every 60 days in two of four records reviewed; in particular client record # 2 and 4.
Client # 2 was admitted to the program on 12/19/12 and was still an active client at the time of review on 3/8/13. The individual treatment plan was documented on 12/19/12. The treatment plan update was due in 60 days or by 2/19/13. The facility failed to document a treatment plan update for client # 2
Client # 4 was admitted to the program on 9/27/12 and was still an active client at the time of review on 3/8/13. The individual treatment plan was documented on 10/25/12. The treatment plan update was due in 60 days or by 12/25/12 and 2/25/13. The facility failed to document a treatment plan update for client # 4.
The Project Director confirmed the findings.
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Plan of Correction
The Program Director has trained the staff on the requirements for treatment planning. Client #2 and 4 will have their treatment plans updated immediately. All clients will have updated treatment plans every 60 days moving forward. The Program Director is responsible for making sure that all treatment plans are updated every 60 days. The Program Director will review each client chart at a minimum of once a month. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record which included a case consultation note in two of two records required.
The findings include:
Two client records requiring documentation of a case consultation were reviewed on March 8, 2013. The facility failed to document a case consultation in two of two records reviewed; in particular client record # 3 and 4.
Client # 3 was admitted to the program on 11/27/12 and was still an active client at the time of review on 3/8/13. Each client's progress should be reviewed at least quarterly at a case conference consisting of representatives from the various client service components. The facility failed to document a quarterly case consultation note for client # 3.
Client # 4 was admitted to the program on 9/27/12 and was still an active client at the time of review on 3/8/13. Each client's progress should be reviewed at least quarterly at a case conference consisting of representatives from the various client service components. The facility failed to document a quarterly case consultation note for client # 4.
The Project Director confirmed the findings.
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Plan of Correction
The Program Director has trained the staff to initiate a case consultation on every client every 60 days. This will insure that each client has a case consultation quarterly. Case consultations will occur at the weekly staff meetings when all staff are present to contribute their input. Clients #3 and 4 will have case consultations completed by April 11,2013. The Program Director is responsible for making sure that case consultations occur quarterly. He will audit all client charts monthly to insure that the case consultations are being completed quarterly. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and a review of the facility's policy and procedure manual, the facility failed to document an aftercare plan which included criteria for re-entry to the program and a plan to provide client support in one of one record required.
The findings include:
The facility policy states: "An aftercare plan for clients who have completed treatment will include future SMART goals, services needed after discharge including services provided by ERC, a plan to provide client support, criteria for re-entry to the program, provision for periodic re-evaluation and termination of the plan."
One client record requiring documentation of an aftercare plan was reviewed on March 8, 2013. The facility failed to document an aftercare plan in accordance with facility policy in one of one record reviewed; in particular client record # 5.
Client # 5 was admitted to the program on 1/31/13 and successfully discharged on 2/28/13. The facility documented an aftercare plan on 2/28/13; however the plan did not include a contact person or the re-entry process.
The Project Director confirmed the findings.
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Plan of Correction
The Program Director has trained all staff to develop an aftercare plan for all clients who successfully complete treatment at ERC. The Program Director is responsible for making sure the aftercare plans are written and include future goals, services needed after discharge, and criteria for re-entry into treatment. The Program's policy (709.94) was amended to state that aftercare plans will include future goals, services needed after discharge and criteria for re-entry into treatment. The Program Director will audit all client charts monthly to insure that aftercare plans are being completed by the counselor when a client is nearing discharge. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records and a review of the facility's policy and procedure manual, the facility failed to document a complete client record which included follow-up information in two of four records reviewed.
The findings include:
The facility's policy states: "When a client is not referred after discharge, an attempt should be made to follow up the ex-client's progress and status and document it on the client follow-up form."
Two client records requiring documentation of follow-up information were reviewed on March 8, 2013. The facility failed to document follow-up information in two of four records reviewed; in particular client record # 6 and 8.
Client # 6 was admitted to the program on 11/13/12 and discharged on 2/5/13 after leaving the facility against staff advice. The facility was required to document a complete client record which included follow-up information. The facility failed to document follow-up information as of 3/8/13.
Client # 8 was admitted to the program on 10/10/12 and discharged on 12/4/12 after leaving the facility against staff advice. The facility was required to document a complete client record which included follow-up information. The facility failed to document follow-up information as of 3/8/13.
The Project Director confirmed the findings.
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Plan of Correction
An improved client follow up system has been developed. Within 30 days after a client is discharged from ERC, a letter will be sent to the client asking about the status of their recovery and if they need additional assistance. ERC's hours and contact information are included in this letter. A client follow up form will be placed in the discharge client file recording the date the letter was sent and any response received. If a client is referred to another resource upon successful completion of outpatient treatment at ERC, ERC will obtain written consent from the client prior to discharge allowing ERC staff to follow up with the resource within one week of the referral being made. This contact will also be documented in the discharge client file. ERC policy has been revised to reflect these changes. ERC policy now states that ERC will contact the former client once within the first 30 days after discharge. The Program Director has trained the staff on this new system. The Program Director is responsible for insuring that discharge client follow occurs as required. ERC will attempt to contact Client #6 and #8 for follow up by April 11, 2013. The Program Director will perform monthly client chart audits and will make sure that any clients nearing discharge have provided accurate contact information to staff for follow up. He will also insure that staff will use the contact information provided at intake to initiate follow up for any client who is unexpectedly discharged. |