INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 21, 2014 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.
|
Plan of Correction
|
704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
|
Observations
Based on a review of the Staffing Requirement Facility Summary Report (SRFSR) and an interview with the Vice President of the Governing Body, the facility failed to employ a Project Director for the overall management of the project and staff.
The findings include:
The licensing inspection took place on March 21, 2014. The licensing specialist was informed by the Vice President of the Governing Body on March 21, 2014, that at this present time the facility didn ' t have any staff including a Project Director.
|
Plan of Correction
Th Empowerment Resurrection Center suspended all treatment services on January 30, 2014. Prior to resuming services ERC will hire a Project Director. The ERC board of Directors wil be responsible for interviewing and selecting a Project Director. A Project Director will be hired before August 30, 2014. |
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 on a review of the fire drill record, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The fire drill record was reviewed on March 21, 2014 for the period of March 2013- January 2014. The facility only documented use of the front door exit during each fire drill.
The facility did not dispute the findings.
|
Plan of Correction
Once ERC hires staff, fire drills will be conducted using an alternate exit. The Project Director will be responsible for training new staff on how to conduct a fire drill and the importance of varying which exit is used during these drills. The exit used will be documneted on the fire drill log. The Project Director will insure that fire drills are conducted in compliance with the regulation. While there are no staff and no clients, the administrative volunteer will conduct fire drills monthly using different exit routes. She will document this on the fire drill log. The vice president of the board of directors will be responsible for making sure these fire drills occur beginning the week of April 28, 2014. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in seven of ten client records reviewed.
The findings include:
Ten client records were reviewed on March 21, 2014. Consent to release forms were reviewed in all records. The consent to release forms exceeded 4 PA Code 255.5 in the following client records, #2, 4, 5, 6, 8, 9 and 10.
Client #2 was admitted on October 17, 2013 and discharged on December 16, 2013. The consent to release form dated October 17, 2013 to the client's parole officer exceeded 4 PA Code 255.5 by allowing the facility to release the client's urinalysis, discharge summary and aftercare plan.
Client #4 was admitted on September 25, 2013 and discharged on December 16, 2013. The consent to release form dated September 25, 2013 to the client's parole officer exceeded 4 PA Code 255.5 by allowing the facility to release the client's discharge summary and aftercare plan. Additionally, a consent to release to the client's prison dated September 25, 2013, also exceeded 4 PA Code 255.5 by allowing the facility to release the client's discharge summary.
Client #5 was admitted on September 17, 2013 and discharged on December 16, 2013. The consent to release forms dated September 17, 2013 to the client's parole officer and client's prison exceeded 4 PA Code 255.5 by allowing the facility to release the client's aftercare plan and urinalysis.
Client #6 was admitted on August 28, 2013 and discharged on December 16, 2013. The consent to release form dated August 28, 2013 to the client's parole officer exceeded 4 PA Code 255.5 by allowing the facility to release the client's aftercare plan and client's treatment.
Client #8 was admitted on August 26, 2013 and discharged on November 18, 2013. The consent to release form dated August 26, 2013 to the client's parole officer exceeded 4 PA Code 255.5 by allowing the facility to release the client's treatment.
Client #9 was admitted on June 24, 2013 and discharged on November 6, 2013. The consent to release form dated September 25, 2013 to the client's parole officer exceeded 4 PA Code 255.5 by allowing the facility to release the client's aftercare plan.
Client #10 was admitted on July 3, 2013 and discharged on September 27, 2013. The consent to release form dated September 24, 2013 to the client's parole officer exceeded 4 PA Code 255.5 by allowing the facility to release the client's aftercare plan.
The facility did not dispute the findings.
|
Plan of Correction
The consent to release information forms in client charts #2, 4, 5, 6, 8, 9,and 10 will be considered invalid. None of the information cited that violates 4 PA Code 255.5 will be released to parole officers or prisons. These clients were discharged from ERC several months ago, so the release forms cannot be redone correctly. When a Project Director is hired, he or she will review 4 PA Code 255.5 and will train the staff on the acceptable conditions and specific infomation that can be released to other agencies. When a new client is admitted to ERC for treatment and a counselor completes the intake process, the Project Director will review the release of information consent forms and check to insure that they have been completed in compliance with 4 PA Code 255.5. The Project Director is responsible for oversight of the proper use of consent to release information. ERC will be in full compliance with this standard by September 15, 2014. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and/or counselor conclusions and impressions in eight of ten records reviewed.
The findings include:
Ten client records were reviewed March 21, 2014. A psychosocial evaluation was reviewed in all client records.
The psychosocial evaluations in client records # 4, 5, 6, 7, 8, 9 and 10 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #2, 4, 5, 6, 7, 8, 9 and 10 did not include an evaluation of the client's support systems.
The psychosocial evaluations in client records #2, 4, 5, 6, 7, 8, 9 and 10 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #5, 6, 7, 9 and 10 did not include an evaluation of the negative factors of the client.
The psychosocial evaluation in client record #9 did not include an evaluation of the counselor conclusions/impressions of the client.
The facility did not dispute the findings
|
Plan of Correction
Clients numbered 2, 4 , 5, 6, 7, 8, 9, 10 were discharged from ERC several months ago and the staff person who completed the psychosocial evaluations is no longer employed by ERC. As a result, the existing psychosocial evaluations in clients records 2 through 10 cannot be corrected. When staff are hired, the program director will train them in how to thoroughly complete a psychosocial evaluation including assessing the client's strengths and how these will impact treatment, the client's support systems, the client's coping mechanisms and how these will relate to treatment, any negative factors of the client and the counselor's conclusions. The program director is responsible for conducting this training and for follwoing up with each counselor and reviewing their psychosocial evaluations to insure that they are applying what was taught in the training. The program director will provide this training to new counselors within 2 weeks of their start date. This training will be documented in their personnel file. |
709.93(a) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
|
Observations
Based on a review of client records, the facility failed to maintain a complete client record for nine of ten client records.
The findings include:
Ten client records were on March 21, 2014. The facility failed to maintain a complete record in client records, #1, 2, 3, 5, 6, 7, 8, 9, and 10.
A review of client records, #1, 2, 3, 5, 6, 7, 8, 9, and 10 failed to include documentation that a follow-up had been completed.
Client #1 was admitted on October 29, 2013 and discharged on December 16, 2013. As of the date of the licensing inspection there was no follow-up documented.
Client #2 was admitted on October 17, 2013 and discharged on December 16, 2013. As of the date of the licensing inspection there was no follow-up documented.
Client #3 was admitted on October 25, 2013 and discharged on December 18, 2013. As of the date of the licensing inspection there was no follow-up documented.
Client #5 was admitted on September 17, 2013 and discharged on December 16, 2013. As of the date of the licensing inspection there was no follow-up documented.
Client #6 was admitted on August 28, 2013 and discharged on December 16, 2013. As of the date of the licensing inspection there was no follow-up documented.
Client #7 was admitted on August 21, 2013 and discharged on December 4, 2013. As of the date of the licensing inspection there was no follow-up documented.
Client #8 was admitted on August 26, 2013 and discharged on November 18, 2013. As of the date of the licensing inspection there was no follow-up documented.
Client #9 was admitted on June 24, 2013 and discharged on November 6, 2013. As of the date of the licensing inspection there was no follow-up documented.
Client #10 was admitted on July 3, 2013 and discharged on September 27, 2013. As of the date of the licensing inspection there was no follow-up documented.
A review of client records, # 9 and 10 failed to include documentation of an aftercare plan.
Client #9 was admitted on June 24, 2013 and successfully discharged on November 6, 2013. As of the date of the licensing inspection the facility failed to document an aftercare plan.
Client #10 was admitted on July 3, 2013 and successfully discharged on September 27, 2013. As of the date of the licensing inspection the facility failed to document an aftercare plan.
A review of client records, #1, 2, 3, 5, 6, 7, 8 and 10 failed to include documentation of discharge summaries.
Client #1 was admitted on October 29, 2013 and discharged on December 16, 2013. As of the date of the licensing inspection the facility failed to document a discharge summary.
Client #2 was admitted on October 17, 2013 and discharged on December 16, 2013. As of the date of the licensing inspection the facility failed to document a discharge summary.
Client #3 was admitted on October 25, 2013 and discharged on December 18, 2013. As of the date of the licensing inspection the facility failed to document a discharge summary.
Client #5 was admitted on September 17, 2013 and discharged on December 16, 2013. As of the date of the licensing inspection the facility failed to document a discharge summary.
Client #6 was admitted on August 28, 2013 and discharged on December 16, 2013. As of the date of the licensing inspection the facility failed to document a discharge summary.
Client #7 was admitted on August 21, 2013 and discharged on December 4, 2013. As of the date of the licensing inspection the facility failed to document a discharge summary.
Client #8 was admitted on August 26, 2013 and discharged on November 18, 2013. As of the date of the licensing inspection the facility failed to document a discharge summary.
Client #10 was admitted on July 3, 2013 and discharged on September 27, 2013. As of the date of the licensing inspection the facility failed to document a discharge summary.
A review of client records, #6, 7 and 9 failed to include documentation of case consultations notes.
Client #6 was admitted on August 28, 2013 and discharged on December 16, 2013. As of the date of the licensing inspection there was no case consultation documented.
Client #7 was admitted on August 21, 2013 and discharged on December 4, 2013. As of the date of the licensing inspection there was no case consultation documented.
Client #9 was admitted on June 24, 2013 and discharged on November 6, 2013. As of the date of the licensing inspection there was no case consultation documented.
The facility did not dispute the findings.
|
Plan of Correction
As of April 10, 2014 follow up letters were sent to each of the clients(numbers 1-3 and 5-10) who did not have a follow up contact documented in their charts. The program director is responsible for making sure that every discharged client has a follow up letter mailed within 30 days of discharge. When a client is discharged, the program director will note on the client tracking calendar when the follow up letter is to be mailed. The program director will check on that date to insure that the counselor mailed the letter and put a copy in the client's chart. The Program Director will train all staff on the importance of developing an aftercare plan with each client prior to discharge and completing a discharge summary on each client after he or she is discharged. The Program Director is responsible for insuring that both these documents are completed and placed in the client charts. Aftercare plans cannot be completed with clients 9 and 10 who are no longer in treatment, but discharge summaries on clients 1-3 and 5-10 will be completed by May 12, 2014. Case consultation notes were not completed on clients 6,7 and 9 because ERC only had one clinical staff person while these clients were in treatment. Moving forward, there will be at least one counselor and a program director on staff at all times, so that case consultations can be completed. Staff are expected to be hired before September 30, 2014 |