INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23, 2022, 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 one personnel record, the facility failed to ensure that each employee had a training plan completed annually.
Employee # 1 was hired as the Project and Facility Director on February 1, 2019 and was still in that position at the time of the inspection. No training plan for the current training year was presented during the inspection process.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 04/01/2022, employee # 1 submitted their proposed training plan for the calendar year 2022. The plan was approved by the CEO of the company. The plan includes the necessary training hours for the title of project director in accordance with DDAP guidelines and regulations. The CEO will ensure the training plan is being followed during monthly meetings with project director. Moving forward, the CEO will ensure the project director is following the guidelines of the training calendar which states training plans for all employee must be submitted by the end of January of the calendar year. The CEO will approve the training plan for the project director. The project director will approve training plans for all other employees. The CEO will ensure this is being followed during a monthly meeting with the project director. |
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
The project failed to ensure that a sufficient number of staff persons were certified in CPR. Based on the review of the Staffing Requirements Facility Summary Report and one personnel record, there was no documentation that the sole employee had current CPR certification.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 04/05/2022, the project director scheduled a CPR training class at the ERC location with a certified CPR trainer in order to update and make current the certification for the project director. The trainer will also certify any other employees of ERC in order to comply with DDAP guidelines and regulations. The project director will ensure staff members are properly trained in CPR by scheduling CPR trainings twice a calendar year so all new employees may take the training. |
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 one personnel record, the facility failed to document the completion of 12 clock hours of annual training required for Project Directors.
Employee # 1 was hired as the Project Director on February 1, 2019 and has remained in that position. The facility's training year that was reviewed was January 2021 through December 2021. Employee #1's employee record did not document any training hours for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 04/01/2022, employee # 1 submitted their proposed training plan for the calendar year 2022. The plan was approved by the CEO of the company. The plan includes the necessary training hours of 12 for the title of project director in accordance with DDAP guidelines and regulations. The CEO will ensure the training plan is being followed during monthly meetings with project director. As of 04/01/2022, employee # 1 submitted their proposed training plan for the calendar year 2022. The plan was approved by the CEO of the company. The plan includes the necessary training hours for the title of project director in accordance with DDAP guidelines and regulations. The CEO will ensure the training plan is being followed during monthly meetings with project director. Moving forward, the CEO will ensure the project director is following the guidelines of the training calendar which states training plans for all employee must be submitted by the end of January of the calendar year. The CEO will approve the training plan for the project director. The project director will approve training plans for all other employees. The CEO will ensure this is being followed during a monthly meeting with the project director. |
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 March 23, 2022, 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.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 04/01/2022, the lightbulb in the vestibule connecting the hallway to the emergency exit was exchanged with a new bulb so that it remains lit at all times. ERC understands the importance of interior exits remaining lit to ensure safety for our clients and staff. The project director will ensure these lights remain in working order by inspection during our monthly fire drill. |
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 fire drill logs from May 2021 through February 2022, the facility failed to ensure that fire drill logs included the exit route used for each fire drill conducted.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 04/01/2022, the "route" was added to the fire drill log to indicate the route of front or back used during the fire drill. The fire drill conducted of 04/08/2022 indicated the route used during the drill. The project director will ensure the route is included on the drill log moving forward. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
The project has a Department-approved exception for this regulation; however, the project failed to provide their 2020 tax returns to the Department, per the exception.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/23/2022, ERC obtained a letter from the IRS through our accountant stating the 990-N for 2020 was accepted on 04/22/2021. ERC received this email too late to present it during the inspection. Moving forward the project director will ensure all tax documents are maintained in the facility prior to inspection date. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of one personnel record, the facility failed to ensure that employees have annual written individual staff performance evaluations signed by the employee in one record reviewed.
Employee #1 was hired as the Project Director on February 1, 2019. The annual performance evaluation presented during the inspection process did not have a time period referenced and was not signed by the employee.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 04/01/2022, employee #1 has signed their performance evaluation for the previous year of 2021. The evaluation was also updated to reference the time period of the 2021 calendar year. The CEO will ensure moving forward all performance evaluations are signed by the employee and the proper time period is indicated. |