INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the March 28, 2012, licensure renewal inspection. The follow-up inspection was conducted on October 23, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 (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 procedures, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings included:
The fire drill procedure was reviewed on October 23, 2012. The fire drill procedure continues to not include the activation of a smoke detector or fire alarm. An exception letter was not presented.
A Board member and the facility director were interviewed on October 23, 2012, at 11:30 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.
This is a repeat citation from the March 28, 2012, renewal inspection.
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Plan of Correction
ERC will purchase a battery powered smoke detector and utilize it for monthly fire drills. The Program Director will monitor the drills and be responsible for making sure they occur monthly and are documented. |
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 make available to the public the annual report.
The findings included:
During the review of administrative documentation, the annual reports for the fiscal year January 1, 2010, to December 31, 2010, and January 1, 2011, to December 31, 2011, were requested for review. The reports were documented. The annual report is to be made available via the website. Upon review of the website, the annual report was not posted.
A dialogue with a Board member and the facility director on October 23, 2012, confirmed the annual reports had not been posted to the website.
This is a repeat citation from the March 28, 2012, renewal inspection.
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Plan of Correction
On November 15, 2012 the ERC annual reports for 2010 and 2011 were posted on the ERC website. The program director will insure that the 2012 annual report is posted to the ERC website by July 1 ,2013. The program director is responsible for making all annual reports accesible to the public. |
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 comprehensive psychosocial evaluation in three of three client records.
The findings include:
Three client records were reviewed on October 23, 2012. All client records were reviewed for the documentation of a psychosocial evaluation.
Client # 1 was admitted on October 3, 2012.
Client # 2 was admitted on October 11, 2012.
Client # 3 was admitted on October 10, 2012.
All client records contained psychosocial evaluations. The evaluations lacked individualized reviews of the clients' information with clinical assessment.
The findings were reviewed with the facility director and confirmed.
This is a repeat citation from the March 28, 2012, renewal inspection.
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Plan of Correction
The psychosoccial evaluation form has been revised to include more specific information about the client's history. The psychosocial evaluations on clients #1, #2, #3 were reviewed and corrected by the counselor under the supervision of the program director. Individualized reviews and clinical assessments of clients #1, #2, #3 are now present in the files. The program director trained the counselor on how to thoroughly and properly review the information and provide detailed assessment. The program director will insure that this does not recur, he is implementing the corrective action. The program director will check client files every two weeks to maintain compliance with this standard. |
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 three of three client records.
The findings included:
Three client records were reviewed on October 23, 2012. All records were reviewed for documentation of the proposed type of support service in the treatment plan.
Client # 1 was admitted on October 3, 2012. The treatment plan was developed on October 10, 2012. No support services were documented on the treatment plan.
Client # 2 was admitted on October 11, 2012. The treatment plan was developed on October 16, 2012. No support services were documented on the treatment plan.
Client # 3 was admitted on October 10, 2012. The treatment plan was developed on October 17, 2012. No support services were documented on the treatment plan.
The findings were reviewed with the facility director and confirmed.
This is a repeat citation from the March 28, 2012, renewal inspection.
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Plan of Correction
The counselor, under the supervision of the program director, added 3 types of support service to the treatment plans of client #1, #2 and #3. The clients will be informed of the support services being recommended by the counselor. Each new client will be referred to 3 types of support services which will be documented on their treatment plan. The counselor has been trained by the program director on how to determine needed support services and document them on the treatment plan. The program director will check the client files every two weeks to insure that treatment plans are completed properly. The program director is responsible for insuring compliance with this standard. |