INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of two personnel records, the facility failed to ensure that one employee had a written individual training plan.
Employee # 1 was hired as the Project Director on January 1, 2023 and was current in that position at the time of the inspection. Employee # 1 did not have documentation of an individual training plan in the personnel record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
704.11(b)(1) Licensure Individual Training Plan
ERC's plan of correction for this deficiency is as follows, every employee will collaboratively work with their Clinical supervisor and Clinical Director to develop a training plan within the first 15 days of their employment with ERC. This training plan will include training that the employees would like to take to further develop their skill sets in the drug and alcohol recovery journey. The employee's training plan with be reviewed with their supervisor on a semi-annual basis and then updated on an annual basis with the clinical director to reflect the training that the employee has received throughout the year. This training plan will also include the yearly required training that is mandatory by our funders. This training plan will be placed in the employee records. This plan of correction action will take place by June 07,2023. Also employee #1 training plan POC started on 05/01/23, and is in the employee records.
1. Training plans will be created within 15 days of hire.
2. Training plans will be reviewed quarterly by the program director
3. Training plans will be reviewed by the clinical supervisor with the employee on a bi-monthly basis.
4. Training plans will be reviewed by the clinical director on a year basis.
Training plans for employees will be reviewed with the ERC training plan committee every 90 days starting on June.07, 2023.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on April 17, 2023, the facility failed to keep the exterior of the building and the building grounds free of hazards. There was yard debris and brush outside of the emergency exit, which posed a potential tripping hazard for those using the exit.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.22 (2) Licensure Building exterior and grounds
ERC's plan of correction for this deficiency is as follows, the building grounds will be inspected by Clinical Director once a week and then any debris and or brushes outside of the fire escape will be reported to the building owner. If the building owner does not remove the debris or brushes, ERC will remove the brushes or debris themselves within 24 hours of reporting this to the building landlord. Clinical Director will begin this weekly inspection of the building on May 25, 2023. Clinical Director will create a weekly inspection log to ensure that this exterior exit is free from debris and brushes immediately. |
705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on April 17, 2023, the facility failed to ensure interior exits were lit at all times.
The light in the vestibule connecting the hallway to the emergency exit stairwell was not lit and the area was pitch black.
This is a repeat citation from the March 23, 2022 annual licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Observation # P247
ERC's plan of correction for this deficiency is as follows, Clinical Director will do an inspection of the interior lighting throughout the fire exit three times a week. If any lights are out in the fire escape Clinical director will report this to the building landlord for repair. If the building landlord does not replace the lightening in the fire exit within 24 hrs. ER will replace the lighting within the next 24 hrs. Clinical Director will create a fire exit lighting log to show the number of times that the fire exits has been inspected as well as any replacement of lighting every week starting on May 29, 2023. The plan will be in full effect on 06/05/2023.
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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 two personnel records, the facility failed to ensure that one staff was instructed in the use of the fire extinguishers upon employment.
Employee #2 was hired as the Facility Director on March 15, 2023 and is still current in this position. Employee #2 was required to be trained in the use of fire extinguishers upon employment; however, the record contained no documentation that fire safety training was completed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 © (4) Licensure Fire Safety
ERC's plan of correction for this deficiency is as follows, all employees will be trained on the facility fire safety training during the orientation process or within 1 week of hire date. This training will be part of the employee's training log annually. All employees will be trained by Program Director and Clinical Director upon hire and annually by the fire safety team. All employees with be trained to know where all fire exits and extinguishers are located. All employees will learn how to operate a fire extinguisher, within the first week of hire. All employees will learn what the word "PASS" means as it relates to fire extinguishers. All employees will receive a fire safety certificate after each fire safety training. This training certificate will be placed in the employee records. This plan of correction will start on May 29, 2023. The plan will be in full effect starting on June 5, 2023. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and a discussion with facility staff, the facility failed to ensure that one staff was trained to perform assigned tasks during emergencies prior to being on shift.
Employee #2 was hired as the Facility Director on March 15, 2023 and is current in that position. Employee #2 began working shifts on March 15, 2023, but the record contained no documentation that the employee was trained to perform assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (d) (3) Licensure Fire Safety
ERC's plan of correction for this deficiency is as follows, all staff members will be trained on how to handle facility emergencies on the date of hire or within 7 days of their orientation by the Project Director and the Clinical Director. A training log will be development to show that the facility emergencies plans has been review and discussed with all employees on the date of hire or before their 7 days of orientation has been completed. An annual training log will be developed to show all staff members have participated in the emergency training plans at least on an annual basis. All staff members will be given a short quiz at the end of their facility emergency training. This training will start on June 17, 2023,
1. Clinical supervisor will be given a company phone to handle all emergency calls after work hours.
2. Clinical supervisor will contact program director after contacting the necessary systems or personnel to handle the situation and or problems.
3. These emergencies will be document and then a brief meeting will take place right after the emergency has been handled.
These documents will be review monthly during the staff meeting, so that every employee is where of how the emergency was handled.
4. There will also be an emergency file folder kept in the office at ERC starting June 17, 2023. |