INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 16, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
The facility failed to ensure that each counselor met the qualifications for the position in two of three applicable personnel records.
Employee # 3 was hired as counselor on February 1, 2019. There was a letter from the university stating the employee was conferred the Doctor of Psychology program; however, there was no transcript or resume to verify a practicum was taken, or experience in a health or human service agency setting.
Employee # 4 was hired as a counselor on February 1, 2019. There was documentation of a Master of Human Services degree; however, there was no transcript or resume to verify if a practicum was taken, or experience in a health or human service agency setting.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Project Director will be responsible to ensure that all new staff records include a resume and/or transcript in their individual files on date of hiring.
The Project Director met with Employee # 3 and Employee # 4 during Supervision to collect and file each resume on April 19th, 2019 in their respective charts. Both employees resumes indicate experience in the Health and Human Service field.
The Project Director and staff will ensure that this deficiency does not occur again by discussing employee chart documentation during supervision.
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
The facility failed to ensure that a counselor assistant was supervised by a full-time clinical supervisor or counselor who meets the qualifications in regulations 704.6 or 704.7 in one applicable personnel record.
Employee # 5 was hired as a counselor assistant on February 1, 2019. There was no documentation of any supervision on file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that all staff supervision is placed in the staff file. The Program Director will meet with the Counselor Assistant(CA) weekly to ensure that the CA receives the proper amount of supervision. The Program Director will be responsible for ensuring that the supervision documentation is placed in the staff chart at the time of the supervision. This should ensure that this does not happen again. |
704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
The facility failed to follow their training and staff development procedure, as the following components were not completed or documented for 2018 and 2019:
1.An assessment of staff training needs.
2.An overall plan for addressing these needs.
3.A mechanism to collect feedback on completed training.
4.An annual evaluation of the overall training plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all new staff be responsible for receiving the trainings as it relates to our training policies.
The Project Director will ensure that all new and current staff be allowed to participate in trainings that has been identified as training needs for individual staff.
The Project Director during staff supervision will ensure that all new staff records include trainings as it relates to our training policy.
The Project Director will meet with staff during an 1 hr. supervision to correct the missing training information in each staff chart. This included
1. identifying and developing staff training needs
2. how to collect the training data once they have completed the training
3. a yearly/annual evaluation and assessment of staff training needs
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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
The facility failed to provide documentation of an individual training plan for the current training year, identified as January 1, 2019 through December 31, 2019, in five of five employee records reviewed
Employee # 1 was hired as the Project Director on February 1, 2019.
Employee # 2 was hired as a counselor on February 1, 2019.
Employee # 3 was hired as a counselor on February 1, 2019.
Employee # 4 was hired as counselor on February 1, 2019.
Employee # 5 was hired as counselor on February 1, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all individual counselor's training plans are placed in the chart for the calendar year 2019. During the hiring process, counselor training needs will be identified and a plan put forth to ensure that the staff follows that training plan. This will be completed by June 1st, 2019
ERC Board of Directors will ensure that the proper training year documents for the Project Manager is included in staff chart. ERC will ensure that the Project Director be allowed to participate in trainings to fulfill his yearly training plan. We will discuss his training plans monthly as we meet monthly.
ERC Board of Directors met with Project Director during April Board meeting to bring Project Director Chart into compliance. The Project Director chart has been completed with all missing training information included. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to ensure that the hot water temperature in the men's bathroom did not exceed 120 degrees Fahrenheit. On April 16, 2019 at approximately 12:00 p.m., the temperature was measured at 127.5 degrees Fahrenheit.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Manager will work closely with the maintenance department of the building to get hot water within the guidelines of 120 degree. The maintenance dept. has been notified about the issue.
ERC purchased a thermometer so it can periodically check the water temperature in the men and ladies bathroom.
The Project Director along with the building maintenance dept will ensure that this does not occur again
The maintenance department has corrected the water temperature issue on 4/27/2019 after meeting with ERC Board of Directors |
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
The facility failed to ensure that interior exits and stairs were lit at all times. Based on a physical plant inspection, the staircase directly across from the suite was missing a light fixure in one section, causing the area to be pitch black.
This information was reviewed with the facility staff during the licensing inspection
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Plan of Correction
The Project Director has contacted the building maintenance dept and the light bulb was replaced with a working light bulb.
In the future the Project Director will work with the maintenance dept as soon as issue has been identified.
The Project Director will ensure that any deficiency relating to fire safety will immediately be addressed and corrected. Also we ERC will develop a form that will be completed during each fire drill
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
The facility failed to ensure that the fire extinguisher in the office was inspected annually. Based upon observation during the physical plant inspection, the extinguisher's last inspection was completed in November 2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Project Director will ensure that the company in charge of yearly inspection continue to fulfill their obligations. The Project Director has called the contractor to ensure they immediately come out and inspect the fire extinguisher located in ERC office. The Project Director will ensure that the fire extinguisher is included in an annual report as a reminder. |
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
The facility failed to document fire extinguisher training upon employment in all five employee records reviewed.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director will ensure that all staff charts are in compliance with Fire Safety and trainings. These training will include training on the proper use of using a fire extinguisher. This training will be completed by 5/10/2019.
The Project Director will ensure that all new staff receive their fire extinguisher training during orientation and that the chart be documented as such. |
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
The facility failed to conduct an unannounced fire drill for the month of November 2018. Additionally, the facility failed to identify, on their fire drill log, the time of the drill, the amount of time it took for the evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative during drills conducted from May 2018 to March 2019. Lastly, the facility failed to conduct fire drills on different days of the week as every fire drill documented in the reviewed timeframe was completed on a Monday.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that fire drills are conducted appropriately will include all information in the future. Fire drills with staff will be done and all information relating to P279 will be recorded. This will start immediately beginning 4/30/2019. |
709.22 (b) (1) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(1) Designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly.
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Observations
The facility failed to provide verification that the governing body designated the position of project director as the person officially responsible to the governing body either directly or indirectly. Employee # 1 was hired as the project director on February 1, 2019. The employee file failed to contain a contract, application, or hire letter for the position at the facility. Additionally, there were no governing body meeting minutes addressing the new appointment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ERC Board of Directors meet bi monthly and approved in the January board meeting for the new Project Director to be hired. This information will be updated in the Project Director file. All information included in #0119 will be included. As of 4/30/2019, the meeting minutes book and the Project Director file were updated. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to document that the project director prepared, annually updated and signed a written manual delineating project policies and procedures. The last director signature was completed in 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that ERC becomes compliance with 0125. The annually updated report, and a signed written manual with policies and procedures are in place as of 4/30/2019.
The Project Director will ensure that he includes his signature when reviewing the policy and procedure manual during ERC March Board of Director's meeting and it's filed appropriately. |
709.26 (a) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(4) Orientation of new employees.
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Observations
The facility failed to implement the written policy and procedure for the orientation of new employees in five of five personnel records.
The facility's policy and procedure stated that each staff member's orientation would be documented on the staff orientation form and placed in the employee file. The facility failed to document orientation for each employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all orientation forms relating to 0181 be implemented in the staff charts. All charts will be completed by 5/10/2019
The Project Director will ensure that all new staff orientation forms be completed and filed appropriately when completed. this process will be completed during orientation.
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709.26 (b) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(1) Application or resume for employment.
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Observations
The facility failed to document an application or resume for employment in two of five personnel records reviewed.
Employee # 3 was hired as a counselor on February 1, 2019.
Employee # 4 was hired as a counselor on February 1, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all staff charts includes their personal application. All applications and resumes are now in the staff chart as of April 30th, 2019.
The Project Director will ensure that all new hires charts/files will include an application and a resume. This will be completed during the hiring process. |
709.26 (c) LICENSURE Personnel management.
§ 709.26. Personnel management.
(c) There shall be written job descriptions for project positions.
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Observations
The facility failed to document written job descriptions for the positions of project director and counselor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all future employees file include a description of there position.
All current staff charts were updated with job description as of 5/6/2019 by the Project Director.
The Project Director will ensure that all new staff files include a job description during the hiring process. This should ensure that this deficiency does not occur again. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to develop and implement policies and procedures to respond to the following unusual incident: Physical assault or sexual assault by staff or a client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all future policies and procedures updates be filed in the ERC policy and procedure manual. 0337 was updated and placed in the policy and procedure manual as of 5/6/2019. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
The facility failed to develop and implement policies and procedures to respond to the following unusual incident: Selling or use of illicit drugs on the premises.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all future policy and procedure be developed and implement and filed with the other policy and procedures. This policy and be developed, implemented and filed as of 5/6/2019 |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
The facility failed to develop and implement policies and procedures to respond to the following unusual incident: Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by a facility, for ambulatory services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all new policies be developed, implemented and filed in the policy and procedure manual for staff to review. This new policy has been filed in the policy and procedure manual as of 5/6/2019. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
The facility failed to develop and implement policies and procedures to respond to the following unusual incident: Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all new policy and procedures be developed, implemented and filed in the policy and procedure manual. This policy has been developed, implemented and filed as of 5/6/2019 |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
The facility failed to develop and implement policies and procedures to respond to the following unusual incident: Theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all new policies and procedures be developed, implemented and filed in the policy and procedure manual. This policy has been developed, implemented and filed in policy and procedure manual as of 5/6/2019 |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to develop and implement policies and procedures to respond to the following unusual incident: Event at the facility requiring the presence of police, fire, or ambulance personnel.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all new policies and procedures be developed, implemented and filed in the policy and procedure manual. This policy was developed, implemented and filed in the policy and procedure manual as of 5/6/2019. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
The facility failed to develop and implement policies and procedures to respond to the following unusual incident: Fire or structural damage to the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all new policies and procedures be developed, implemented and filed in the policy and procedure manual. This policy has been developed, implemented and filed in the policy procedure manual as of 5/6/2019. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
The facility failed to develop and implement policies and procedures to respond to the following unusual incident: Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that all new policies be developed, implemented and filed in the policy and procedure manual. This policy has been developed, implemented and filed in policy and procedure manual as of 5/6/2019. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
The facility failed to conspicuously display the project hours of operation to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director will ensure that another bigger sign be placed at the front door to display hours of operations which is 5pm - 8pm. A new sign was placed at the front door displaying proper hours of operation as of 5/6/2019. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
The facility failed to conspicuously display a telephone number for emergency purposes to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director has a new signed displayed at the office door with our hours and phone number on it. This was completed on 5/4/2019 |