INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on March 28, 2012, 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of employee personnel and training records, the facility failed to document that each employee received fire extinguisher training upon hire.
The findings included:
Two personnel records were reviewed on March 28, 2012. Each record was required to have documentation that they received fire extinguisher training upon hire.
Employee # 1 was hired on September 30, 2011. Fire extinguisher training was not documented as of the date of the review.
Employee # 2 was hired on October 27, 2011. Fire extinguisher training was not documented as of the date of the review.
The findings were reviewed with a member of the Board and confirmed.
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Plan of Correction
Both employees have now had fire extinguisher training. This training was completed on 4-10-12. There is documentation in both personnel files showing that this training has been completed. Jill Walters, Vice President Board of Directors, completed the training with the staff. She will be responsible for training all new staff and volunteers on fire extinguisher safety immediatly upon hire. This training is now part of new employee orientation. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on March 28, 2012. The fire drill log was reviewed for documentation of fire drills from the time period of April 2011 to March 2012. The facility failed to documented on the fire drill logs that a smoke detector or fire alarm had been activated for the monthly fire drills documented during this period.
A Board member was interviewed on March 28, 2012, at 11:45 a.m. and confirmed the fire alarm was not activated each month. The facility does use a hand held smoke detector to announce a fire. The building has an interconnected system.
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Plan of Correction
ERC is applying for an exception to this requiremnt because we cannot test the alarm for the building. There are over 25 separate offices/businesses in the building. We have requested proof from the building manager that the building's smoke detectors and alarm system have been tested. We are waiting on that documentation before submiting the written request for exception. The staff continue to ring a bell and exit the building as a monthly fire drill and document this in the office. Jill Walters is responsible for submitting the exception request. The documentation should be available by May 5, 2012. The exception request will be submitted by May 8, 2012. |
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 review of facility administrative documentation, the facility failed to complete an annual report for the fiscal year of January 1, 2010 to December 31, 2010.
The findings included:
During the review of administrative documentation, the annual report for the fiscal year January 1, 2010, to December 31, 2010, was requested for review.
A dialogue with a Board member on March 28, 2012, confirmed an annual report had not been completed to provide to the public.
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Plan of Correction
An annual report for fiscal year 2010 has been completed. This report was completed on 4-25-12 and is available in the ERC office for review. Jill Walters is responsible for completing the annual report for 2010. The annual report for 2011 will be completed by Jill Walters before June 30, 2012. The program manager will be responsible for the annual report for 2012. This report will be completed by June 30 each year. |
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 facility administrative documentation, the facility failed to document an annual audit of financial activities.
The findings included:
During the review of administrative documentation, the fiscal documents were requested. The facility had not completed an audit for fiscal year 2010.
During a dialogue with a Board member on March 28, 2012, it was confirmed an annual audit had not been completed.
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Plan of Correction
ERC's annual gross income for 2010 was far less than $500,000. The anticipated and actual gross income for 2011 was also well below $500,000. ERC requested an exception to 28 Pa.Code 709.25(a)which was mailed on April 14, 2012. The alternative procedure for fiscal oversight is the use of a Certifed Public Accountant who reviews ERC's bank statements, employee time sheets, budget, etc. He also files taxes on behalf of ERC. The accountant reviewed all financial documents on March 10, 2012 prior to completing 2011 tax forms. Jill Walters was responsible for requesting the exception. This exception will be requested for each fiscal year that ERC does not anticpate gross income above $500,000. The exception will be requested by February of the following year. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to provide results of reference checks in one of two personnel records.
The findings included:
Two personnel records were reviewed for reference checks on March 28, 2012. The facility failed to document the results of reference checks in personnel record # 2.
Employee # 2 was hired on October 27, 2011. No reference checks were documented in the personnel record as of the date of the review.
The findings were reviewed with a member of the Board and confirmed.
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Plan of Correction
Reference checks on Employee #2 have been completed. The forms are in the personnel file. Ramona Goff, board member, was responsible for completing them. When a new employee is hired, the Program Manager will be responsible for checking the personnel checklist to insure that all documents have been completed, including reference checks. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of personnel records, the facility failed to document salary information in two of two personnel records.
The findings include:
Two personnel records were reviewed on March 28, 2012. Personnel record #1 and 2 did not include documentation of salary information.
Employee #1 was hired on September 30, 2011. There was no documentation of salary information as of the date of the review.
Employee #2 was hired on October 27, 2011. There was no documentation of salary information as of the date of the review.
The findings were reviewed with a member of the Board and confirmed.
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Plan of Correction
Both employee records now have verification of salary present. The two employees signed forms verifying their salaries on 4/10/12. Jill Walters was responsible for completing these forms with employees. Effective 4/15/2012 the program manger will be responsible for insuring that all new employees sign a salary verification form. This form has been added to all personnel files and is now a part of new employee orientation. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of the client records, the facility failed to document consents to release information which identified the specific information to be disclosed in one of one client records.
The findings include:
One client record was reviewed on March 28, 2012. The consent to release information in record # 1 did not indicate what specific information was to be released to the party whom the disclosure was being made.
The findings include:
Client # 1 was admitted to treatment on January 19, 2012. A consent to release information was signed for an individual with an uncertain relationship to the client. The information identified "general condition" to be released.
The findings were reviewed with a member of the Board and confirmed.
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Plan of Correction
On 4/10/12 this consent to release information was corrected to reflect the relationship of the person information could be released to and the specific information that could be released (the client's presence in treatment program, progress on identified treatment issues). Jill Walters was responsible for eductaing staff about this issue. The program manger is now responsible for reviewing all client files and making sure all release forms are properly completed. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history in one of one client records.
The findings include:
One client record was reviewed on March 28, 2012. The client record required the documentation of a medical history. The facility failed to provide documentation of a medical history in client record # 1.
Client # 1 was admitted on January 19, 2012. The facility failed to document the completion of a medical history as of the date of the review.
The findings were reviewed with a member of the Board and confirmed.
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Plan of Correction
The medical history portion of the psychosocial evaluation has been expanded to include more questions in order to get a fuller medical history from the client. Client #1 has signed consent to release information so that his doctor can be contacted for information about his medical history as needed. This would supplement the medical information the client has disclosed.
The staff member has been trained to gather more thorough medical history from clients during intake.
The staff member has also been trained on how to properly fill out a consent to release confidential information in order to make the information being obtained or disclosed as specific as possible. Jill Walters educated the staff about this issue. The psychosocial evaluation was revised to include more questions about medical history. The program manager is responsible for requesting medical history from a physician for each new client. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug and alcohol history in one of one client records.
The findings include:
One client record was reviewed on March 28, 2012. The client record required the documentation of a drug and alcohol history. The facility failed to provide documentation of a drug and alcohol history in client record # 1.
Client # 1 was admitted on January 19, 2012. The facility documented a history of drug and alcohol use that failed to document current use and the length and patterns of use.
The findings were reviewed with a member of the Board and confirmed.
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Plan of Correction
The substance use history form has been revised to include more questions about a client's current and past patterns of substance use.
A substance abuse history form is present that details the client's history of use. Jill Walters trained staff members to gather specific information on substance use patterns. The revised form is now in all the client files so that each new client will be asked more questions about their current use and patterns of use. Effective 4/15/12, the program manager is responsible for insuring that a thorough substance use history is completed at intake. |
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, the facility failed to document a psychosocial evaluation in one of one client records.
The findings include:
One client record was reviewed on March 28, 2012. The client record required the documentation of a psychosocial evaluation. The facility failed to provide documentation of a psychosocial evaluation in client record # 1.
Client # 1 was admitted on January 19, 2012. The facility failed to document the completion of a psychosocial evaluation as of the date of the review.
The findings were reviewed with a member of the Board and confirmed.
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Plan of Correction
A psychosocial evaluation form was created which will be completed after each cleint's intake. This evaluation was completed for client #1 on 4/14/12. This form was explained to the staff by Jill Walters and is now part of each cleint file to be completed as part of intake. The program manger is responsible for insuring that this evaluation is completed on each new client. |
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 the review of client records, the facility failed to document the proposed type of support service on each treatment plan in one of one client record.
The findings included :
One client record was reviewed on March 28, 2012. The record was required to document the proposed type of support service in the treatment plan.
Client # 1 was admitted on January 19, 2012. The Comprehensive treatment plan was formulated on January 26, 2012. No support services were documented on the treatment plan.
The findings were reviewed with a member of the Board and confirmed.
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Plan of Correction
Recommended support services have been added to client #1's treatment plan. Staff have been educated that all clients must have recommeded support services documented on their treatment plans. Jill Walters was responsible for educating staff about this issue. Effective 4/12/2012 the program manager is responsible for checking all client files to insure that support services are documented. |