INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2025, 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that three of three employees received a minimum of six hours of HIV/AIDS and four hours of TB/STD training using a Department approved curriculum within the regulatory timeframe.
Employee # 1 has been in the position of program director since January 1, 2023 and was due to have the communicable disease trainings no later than January 1, 2025. There was documentation that the employee only received 1.25 training hours of HIV/AIDS and 1.25 training hours of TB/STD at the time of the inspection.
Employee # 2 has been in the position of facility director since March 15, 2023 and was due to have the communicable disease trainings no later than March 15, 2025. There was documentation that the employee only received 1.25 training hours of HIV/AIDS and 1.25 training hours of TB/STD at the time of the inspection.
Employee #3 has been in the position of counselor since February 1, 2024 and was due to have the communicable disease trainings no later than February 1, 2025. There was documentation that the employee only received 1.25 training hours of HIV/AIDS and 1.25 training hours of TB/STD at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of personnel records, the facility failed to ensure that three of three employees received a minimum of six hours of HIV/AIDS and four hours of TB/STD training using a department approved curriculum within the regulatory timeframe.
Employee # 1 The program director has been notified of the recommended number of training hours that are required for communicable diseases (6 Hours HIV/AIDS training and four hours of TB/STD training). These training courses will be completed by June 30, 2025. The program director will sign up for these training through the DDAP training portal by 4/30/2025.
Employee # 2 has been in the position of facility director, has been notified of the recommended number of training hours that are required for communicable diseases (6 Hours HIV/AIDS training and four hours of TB/STD training). These training courses will be completed by June 30, 2025. The facility director will sign up for these training through the DDAP training portal by 4/30/2025.
Employee #3 has been in the position of counselor has been notified of the recommended number of training hours that are required for communicable diseases (6 Hours HIV/AIDS training and four hours of TB/STD training). These training courses will be completed by June 30, 2025. The counselor will sign up for these training through the DDAP training portal by 4/30/2025.
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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 personnel records, the facility failed to ensure that the project director complete at least 12 clock hours of training annually.
Employee #1 was hired as the project director on January 1, 2023 and was a current employee at the time of the inspections. There were no documented training hours for the 2024 training year in the personnel record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will take at least 12 training hours a year or more on the DDAP training portal, some training will be on HIV/AIDS and TB/STD training, etc. The project Director will also take some outside training that may be relevant to his position as of 04/21/2025. These training courses will also be recorded on the project director's training log. The facility director will check quarterly each year to ensure that the project director has completed at least 3 hours of DDAP drug and alcohol required training by reviewing the project director's training logs 3 times a year. |
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 personnel records, the facility failed to document an annual written staff performance evaluation in two of three personnel records reviewed.
Employee #1 was hired as the project director on January 1, 2023 and was a current employee at the time of the inspections. An annual written staff performance evaluation was not documented in the record.
Employee #2 was hired as the facility director on March 15, 2023 and was a current employee at the time of the inspections. An annual written staff performance evaluation was not documented in the record.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on a review of personnel records, the facility failed to document an annual written staff performance evaluation in two of three personnel records reviewed.
Employee #1 was hired as the project director on January 1, 2023, and was a current employee at the time of the inspections. An annual written staff performance evaluation was not documented in the record. The president of the board of ERC will meet with the project director for supervision at least once a year and then do an annual performance evaluation one a year. These encounters will be placed on the team calendar and alerts will be sent out twice a year starting on 4/21/2025. These encounters will also be placed in the project director's file.
Employee #2 was hired as the facility director on March 15, 2023, and was a current employee at the time of the inspections. An annual written staff performance evaluation was not documented in the record. The president of the board of ERC will meet with the facility director for supervision at least once a year and then do an annual performance evaluation one a year. These encounters will be placed on the team calendar and alerts will be sent out twice a year starting on 4/21/2025. These encounters will also be placed in the facility director's file.
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