INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 9, 2011 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 and a plan of correction is due on April 13, 2011.
|
Plan of Correction
|
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
|
Observations
Based on a review of administrative materials, the facility's policy and procedure manual and a discussion with the project director, the facility failed to formulate annual goals and objectives to be presented to the governing body.
The findings include:
The facility's policy and procedure manual and administrative materials were reviewed on March 9, 2011. Goals and objectives were included in the policy and procedure manual for review, but were dated and signed by the board on 10/24/2009. There was no documentation of annual goals and objectives for 2010.
During a discussion with the project director, she stated that annual goals and objectives were not developed or presented to the board since October 2009. She stated she was unaware she had to do this each year and indicated she would have this done at the board meeting coming up in less than a week.
|
Plan of Correction
The Program Director and Board of Director updated the annual goals and objectives and these were approved by the Board at the March 12, 2011 Board meeting. Goals and obejctives will be formulated annually and presented to the Board for review/approval annually. The Program Director will be responsible for monitoring this for continued compliance. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
|
Observations
Based on a review of administrative materials, the facility's policy and procedure manual and a discussion with the project director, the facility failed to document a performance report summarizing the progress towards meeting goals and objectives.
The findings include:
The facility's policy and procedure manual and administrative materials were reviewed on March 9, 2011. There was no documentation of a performance report summarizing the progress towards meeting the 2009 goals and objectives.
During a discussion with the project director, she stated that a performance report had not been completed.
|
Plan of Correction
The Program Director and Board of Directors made a performance report summarizing the progress towards meeting the 2009 goals. These were approved at the March 12,2011 Board Meeting. The performance report will be formulated and presented to the Board for review and approval annually. The Program Director is responsible for monitoring this for continued compliance. |
709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
|
Observations
Based on a review of the facility's policy and procedure manual and a discussion with the project director, the facility failed to have a written policy on employee rights that included the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
The findings include:
The facility's policy and procedure manual was reviewed on March 9, 2011. The facility had a written policy on employee rights, but it did not include the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
During a discussion with the project director, she acknowledged that the policy on employee rights did not include the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
|
Plan of Correction
The Program Director added a statement in the policy manual which said "the employee has a right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records." |
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.
|
Observations
Based upon an interview with the project director, the facility failed to conduct fire drills at least once a month.
The findings include:
Fire drill records were requested for review on March 9, 2011. The project director stated that fire drills had not been conducted since the facility became licensed in June 2010.
|
Plan of Correction
Fire drill records had not been kept since the program has not begun operation yet. The Program Director will begin having fire drills once a month and documenting them. As more staff and clients come on board, they will be required to participate in the fire drills. Until that happens, the Program Director will do the fire drills and document them monthly herself. |
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.
|
Observations
Based upon an interview with the project director, the facility failed to document that fire drills were conducted during normal staffing conditions.
The findings include:
Fire drill records were requested for review on March 9, 2011. The project director stated that fire drills had not been conducted during normal staffing conditions since the facility became licensed in June 2010.
|
Plan of Correction
The Project Director, will document that fire drills are conducted during normal staffing conditions. The record will be kept in the ERC office. |
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.
|
Observations
Based upon an interview with the project director, 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:
Fire drill records were requested for review on March 9, 2011. The project director stated that a fire drill record did not exist.
|
Plan of Correction
The Program Director will 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 record will be kept in the ERC office. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based upon an interview with the project director, the facility failed to document that alternate exit routes were used during fire drills.
The findings include:
Fire drill records were requested for review on March 9, 2011. The project director stated that fire drills had not been conducted since the facility became licensed in June 2010. Therefore, alternate exits were not used during fire drills.
|
Plan of Correction
The Program Director will document that alternate exit routes were used during fire drills. The record will be kept in the ERC office. |
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.
|
Observations
Based upon an interview with the project director, the facility failed to document that fire drills were conducted on different days of the week, at different times of the day and on different staffing shifts.
The findings include:
Fire drill records were requested for review on March 9, 2011. The project director stated that fire drills had not been conducted since the facility became licensed in June 2010.
|
Plan of Correction
The Program Director will document that fire drills are conducted on different days of the week, at different times of the day and on different staffing shifts. This record will be kept in the ERC office. |
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.
|
Observations
Based upon an interview with the project director, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
Fire drill records were requested for review on March 9, 2011. The project director stated that fire drills had not been conducted since the facility became licensed in June 2010. Therefore, a fire alarm or smoke detector was not set off.
|
Plan of Correction
A smoke detector has been placed in the ERC office by the President of the Board. This smoke detector will be set off during each fire drill by the Program Director. A record of this will be kept in the ERC office. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of administrative materials, the facility's policy and procedure manual and a discussion with the project director, the facility failed to develop an overall training plan.
The findings include:
The facility's administrative materials and policy and procedure manual were reviewed on March 9, 2011. An overall training plan was not presented for review.
During a discussion with the project director, she stated that an overall training plan had not been developed.
|
Plan of Correction
The Program Director and Board President have developed a comprehensive staff development program for agency personnel. The policies and procedures for the program indicating who is responsible and the time frames for completion of the following components are in the policy manual. An overall plan for addressing training needs is in a binder in the ERC office. The Program Director will be responsible for monitoring this for continued compliance. |