INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11, 2026 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)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure individual training plans were developed based upon each employee's previous education, experience, current job functions, and job performance in three of three personnel records reviewed. At the time of the inspection, each employee reviewed had a current individual training plan that were identical to each other and listed all the same training courses. It appeared that the training plans were not based upon the employee ' s previous education, experience, and current job functions and performance. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
704.11 (b)(2) & (3) Licensure
Plan to Prevent Recurrence
To prevent recurrence, the facility has implemented the following corrective actions:
· A revised Individual Training Plan format that requires documentation of:
Previous education and professional credentials
Relevant work experience
Current job functions
Most recent performance evaluation results
· Supervisors will complete an individual training needs assessment for each employee prior to creating or updating a training plan.
· Training subjects will be selected based solely on identified needs rather than a standardized list of courses, in accordance with subsections 704.11(d)-(g).
· All supervisory staff responsible for personnel files will be educated on the regulatory requirements of 704.11(b)(2) and (3).
Monitoring / Quality Assurance
· The Administrator or designee will conduct quarterly audits of individual training plans to ensure they are individualized and aligned with employee roles and performance.
· Findings will be documented and reviewed during management meetings.
· Any deficiencies identified during audits will result in immediate correction and retraining of supervisory staff, if necessary.
Responsible Person(s)
· Administrator
· Program Director / Supervisor
· Staff Development or Training Coordinator
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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 and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in two of three personnel record reviewed.Employee #2 was hired as the facility director on March 15, 2023. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than March 25, 2025. There was documentation indicating that only 4.25 hours of HIV/AIDS training was completed and there was no documentation indicating the TB/STD training was completed as of the date of the inspection. Employee #3 was hired as a counselor on February 1, 2024. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than February 1, 2025. There was documentation indicating that only 3 hours of HIV/AIDS training was completed and there was no documentation indicating the TB/STD training was completed as of the date of the inspection. This is a repeat citation from the March 18, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
704.11 (c) (1) Licensure
Corrective Action for Affected Staff
1. Employee #2 (Facility Director):
o Employee #2 was immediately enrolled in a department approved curriculum to complete the remaining HIV/AIDS training hours and the full TB/STD and other health topics training.
o All required training will be completed, and certificates of completion placed in the personnel file.
2. Employee #3 (Counselor):
o Employee #3 was immediately enrolled in a department approved curriculum to complete the remaining HIV/AIDS training hours and the full TB/STD and other health topics training.
o Training completion certificates will be obtained and filed.
- Established a centralized training compliance tracking log for all staff and volunteers
- Implemented training deadline alerts at 6 month, 3 month, and 30 day intervals prior to regulatory due dates
- Required quarterly personnel file audits focusing on mandatory training compliance
Staff Training and Education
- Administrative and supervisory staff were retrained on:
o Regulatory requirements of 704.11(c)(1)
o Training timelines based on staff classification
o Documentation and record retention requirements
- All new hires will receive written notice of communicable disease training requirements at orientation.
Monitoring and Quality Assurance
- The Facility Director or designer will conduct:
o Monthly reviews of the training compliance log for 6 months
o Quarterly audits thereafter
- Results will be reviewed during Quality Assurance meetings
- Any identified gaps will be corrected immediately and documented
Systemic Corrective Actions to Prevent Recurrence
To prevent recurrence of this deficiency, the facility has implemented the following corrective measures:
- Established a centralized training compliance tracking log for all staff and volunteers
- Implemented training deadline alerts at 6 month, 3 month, and 30 day intervals prior to regulatory due dates
- Required quarterly personnel file audits focusing on mandatory training compliance
- Integrated communicable disease training verification into the annual performance and compliance review process
- Updated the staff development policy to specify accountability for monitoring and documentation
The Director of Operations and Quality Assurance Manager are responsible for implementation and monitoring of this Plan of Correction.
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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 the project director and the facility director completed at least 12 clock hours of annual training during the facility's January 2025 through December 2025 training year in one of two applicable personnel records reviewed.Employee #1 was hired as the project director on January 1, 2023. There were zero training hours documented in the personnel record for the reviewed period.This is a repeat citation from the March 21, 2024 and March 18, 2025 annual licensing renewal inspections. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
OO75-704.11(d)(2) Staff development program
704.11(d)(2) LICENSURE
3. Immediate Corrective Actions Taken
- The Project Director was notified of the regulatory training requirements.
- The Project Director completed twelve (12) clock hours of approved training covering the required subject areas outlined in 704.11(d)(2) on [date(s)].
- Training certificates and documentation were obtained and placed in the Project Director's personnel file on [date].
- All current personnel records for leadership staff were reviewed to ensure that required training documentation was present and up to date.
4. Systemic Corrective Actions to Prevent Recurrence
To prevent recurrence of this deficiency, the facility will implement the following measures:
1. Training Tracking System:
A centralized training log will be established and maintained for all Project Directors and Facility Directors, documenting training topic, date, clock hours, and proof of completion.
2. Annual Training Schedule:
An annual training calendar will be developed at the start of each training year to ensure completion of at least twelve (12) clock hours in required subject areas.
3. Assigned Responsibility:
The Facility Director is designated as responsible for tracking, verifying, and maintaining documentation of leadership training requirements.
4. Policy Revision:
The staff development policy will be revised to explicitly include annual training requirements for Project Directors and Facility Directors as outlined in 704.11(d)(2).
5. Staff Education:
Leadership staff will be educated on regulatory training requirements and documentation expectations upon hire and annually thereafter.
5. Monitoring and Ongoing Compliance
- Personnel training files for Project Directors and Facility Directors will be audited quarterly.
- Compliance results will be reviewed by facility administration.
- Any identified deficiencies will be corrected immediately and addressed through additional training and supervision.
6. Responsible Person(s)
- Facility Director
- Compliance/Administrative Designee
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure counselors completed at least 25 clock hours of annual training during the facility's January 2025 through December 2025 training year in one of one applicable personnel record reviewed.Employee #3 was hired as a counselor on February 1, 2024. There were 4.5 training hours documented in the personnel record for the reviewed period.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
0075 Licensure
Corrective Action for the Affected Individual
Employee #3 completed the remaining required training hours to meet the 25 hour annual requirement. All completed trainings addressed required subject areas under §704.11(f)(2), including ethics, confidentiality, treatment planning, counseling techniques, and substance abuse trends. Documentation of completion has been placed in the employee's personnel record.
Systemic Corrective Actions to Prevent Recurrence
1. A training tracking log has been implemented for all counselors to monitor completed and remaining annual training hours.
2. The facility established a semi annual review schedule to ensure counselors remain on track to meet the 25 hour annual requirement.
3. Supervisory staff will receive responsibility for verifying compliance during routine personnel file reviews.
4. New counselors will receive written training requirements during onboarding, including required topics and annual minimums.
5. A standardized training documentation checklist has been added to personnel files.
Monitoring and Ongoing Compliance
The Program Director or Designee will review training records quarterly to ensure each counselor is progressing toward the required 25 annual training hours. Compliance results will be documented and reviewed during quality improvement meetings. Immediate corrective action will be taken if deficiencies are identified.
Program Director / Clinical Supervisor
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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.At the time of the inspection, conducted at approximately 10:00am, the facility's sole bathroom did not have any paper towels available or a mechanical dryer.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
P195-705-24(2) Corrective Action for the Affected Area
Immediately following the inspection, paper towels were restocked in the facility bathroom to ensure availability for hand drying in compliance with 705.24(2).
4. Systemic Changes to Prevent Recurrence
The facility has implemented the following corrective measures:
A wall‑mounted paper towel dispenser has been permanently installed in the bathroom.
Paper towel stock will be maintained on‑site at all times.
Daily bathroom supply checks have been added to the facility's opening and closing procedures.
A back‑up supply of paper towels will be stored in a designated area accessible to staff.
5. Monitoring and Compliance Assurance
The Facility Manager (or designee) will conduct and document daily restroom checks to verify the presence of:
sink
Wall mirror
Operable soap dispenser
Paper towels or mechanical dryer
Compliance will be reviewed weekly for the first 30 days and monthly thereafter. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection, the facility failed to maintain a minimum of two exits on every floor, with both exits being separated by a minimum distance of 15 feet.At the time of the inspection, the facility is located on the second floor and use a stairwell as one exit and a set of elevators as the second exit. However, during emergency fire evacuations and fire drills, elevators cannot be used as an exit. Since elevators cannot be used as an exit from the facility, the stairwell was the only option to exit the facility. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
# P241-705.28(a)(1)(ii) ? Fire Safety (Exits)
Empowerment Resurrection Center's POC
419 Avenue of The States STE 200 Chester Pa. 19013
Email Address: ERCofChester@gmail.com Phone Number: (610) 986-6162
ERC's 30-Day Plan of Correction
Second Exit: Two Story Fire Escape Ladder Installation
Priority: Fire Marshal Inspection & Approval
Phase 1: Immediate Action & Fire Marshal Engagement (Days 1?7)
Objective:
Initiate compliance immediately and secure Fire Marshal involvement before installation.
Actions:
1. Schedule Fire Marshal Inspection (Priority Action)
o Contact local Fire Marshal Code Enforcement within 24?48 hours.
o Request site inspection and guidance for second exit fire ladder installment, anchoring, and code compliance.
2. Conduct Site Assessment
o Identify best egress point from second floor to ground level.
o Confirm:
Clearance
Distance from primary exit
Safe landing area
3. Engage with Qualified Contractor
o Obtain written estimate and design specifications for:
Wall-mounted ladder system
Anchorage compliance
Material (fire-rated and code compliant)
4. Implement Interim Fire Safety Measures
o Increase fire drill frequency (minimum weekly)
o Assign staff roles for assisted evacuation
o Ensure all exits remain unobstructed
Responsible Parties:
- Program Director / Facility Administrator
- Building Manager
- Licensed Contractor
Evidence:
- Fire Marshal inspection request confirmation in a written statement or document
- Contractor estimates and proposal
- Updated fire drill logs
- Interim safety memo to staff
Phase 2: Design Approval & Permitting (Days 8?15)
Objective:
Obtain Fire Marshal approval and ensure installation is code-compliant prior to work.
Actions:
1. Fire Marshal On-Site Inspection
o Review ladder location, design, and safety considerations.
o Obtain written recommendations or approval of conditions.
2. Finalize Ladder Design
o Ensure ladder:
Extensions from second floor to ground
Is anchored to wall with secure mount
Meets spacing and load requirements
3. Apply for Required Permits
o Submit plans to city/building department (if required)
o Include Fire Marshal input
4. Order Materials / Schedule Installation
o Confirm delivery and installation timeline
Responsible Parties:
- Contractor
- Property Management
- Facility Administrator
Evidence:
- Fire Marshal inspection documentation
- Approved design plans
- Permit application/approval (if needed)
- Purchase/work order documentation
Phase 3: Installation & Compliance Verification (Days 16?25)
Objective:
Complete installation and prepare for final inspection.
Actions:
1. Install Fire Escape Ladder
o secure ladder to building structure
o Ensure:
Proper angle and spacing
Slip-resistant rungs
Safe ground landing
2. Conduct Internal Safety Check
o Verify ladder accessibility from second floor
o Remove obstructions
o Install directional signage
3. Update Emergency Evacuation Plan
o Include ladder as designated secondary exit
o Distribute updated plan to staff
4. Train Staff
o Hands-on demonstration of ladder use
o Reinforce evacuation roles
Responsible Parties:
- Contractor
- Safety Officer / Program Director
Evidence:
- Installation photos
- Contractor completion statement
- Updated evacuation plan
- Staff training logs
Phase 4: Fire Marshal Final Inspection & Sign-Off (Days 26?30)
Objective:
Obtain official approval to achieve compliance.
Actions:
1. Request Final Fire Marshal Inspection
o Provide documentation of completed installation
2. Address Any Deficiencies Immediately
o Make same-day or next-day corrections if cited
3. Obtain Written Approval / Sign-Off
o Fire Marshal clearance documentation
4. Submit Compliance Update to Licensing Authority
o Include:
Photos
Inspection approval
Completion timeline
5. Initiate Weekly Status Reporting (if ongoing requirement)
o As requested by licensing authority
Monitoring & Sustainability
- Conduct monthly fire drills using ladder
- Include ladder use in new staff orientation
- Perform quarterly safety inspections of ladder stability
- Maintain ongoing communication with Fire Marshal if needed
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705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection, the facility failed to clearly indicate exits by the use of signs.At the time of the inspection, conducted at approximately 10:00am, the facility's main exit to the 2nd floor corridor did not have posted exit signs indicating which direction the regular and emergency exits were. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
P245-705.28(a)(1)(iv) Plan of Correction
Regulation Cited: Fire Safety: Exits
Corrective Action Taken for the Individual Deficiency
The facility installed clearly visible, illuminated exit signage at the main exit to the 2nd floor corridor. The signage includes directional arrows clearly indicating the proper route to regular and emergency exits in compliance with fire safety requirements.
Measures to Prevent Recurrence
The facility will conduct quarterly environmental safety inspections to ensure all exits are properly marked with visible and compliant exit signage. Exit signage placement and visibility will be added as a required item on the facility's ongoing safety checklist. Any missing or noncompliant signage will be addressed immediately upon identification.
Person Responsible
The Facility Director (or Maintenance Supervisor) is responsible for ensuring exit signage is properly installed, maintained, and routinely inspected. |
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.
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Observations
Based on a review of the facility's March 2025 through February 2026 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day, and on different staffing shifts. The facility's posted hours of operation are Monday through Friday 8:30AM - 5:00PM and Saturday 11:00AM - 3:00PM. Every fire drill conducted during the review period were completed between 3:30PM - 5:00PM. None of the fire drills were conducted during the morning hours of operation. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
P283-Citation: 705.28(d)(6)? Fire Safety ? Fire Drills
Corrective Action Fire Safety Taken for the facility.
There were no resident or participant injuries or emergencies related to this finding. To immediately address the identified area of noncompliance, facility leadership reviewed current fire safety practices and confirmed operational hours and staffing coverage to ensure future drills can be conducted at varied times and shifts.
Corrective Action to Prevent Recurrence
To prevent recurrence of this deficiency, the facility has implemented the following corrective actions:
Fire Drill Schedule Development:
A written fire drill schedule has been developed to ensure drills are conducted on different days of the week, during both morning and afternoon hours, and across all applicable staffing shifts, including Saturday operations, when scheduled.
Policy Reinforcement:
Fire safety and emergency preparedness procedures were reviewed with supervisory staff to reinforce regulatory requirements related to varied fire drill timing.
Staff Education:
All staff were re‑educated on fire drill procedures and expectations, including participation during varied shifts and times of day. Documentation of education has been completed and maintained in staff training files.
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4. Monitoring and Quality Assurance
To ensure ongoing compliance:
Fire drill logs will be reviewed monthly by facility management to verify that drills are conducted on different days and at varied times and staffing shifts.
Monitoring findings will be documented and maintained on-site for licensing review.
Any identified scheduling issues will be immediately corrected, and additional staff guidance will be provided as needed.
Compliance will be incorporated into ongoing quality assurance oversight.
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5. Person(s) Responsible
Primary Responsible Person: Facility Administrator / Director
Secondary Responsible Person: Safety Officer or Designee |
705.28 (d) (8) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(8) Prohibit the use of elevators during a fire drill or a fire.
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Observations
Based on an administrative review of the facility's March 2025 through February 2026 fire drill logs, the facility failed to prohibit the use of elevators during a fire drill or a fire.The facility reported conducting 48 fire drills during the reviewed period. The facility documented using the elevator as the evacuation exit route during 23 of the fire drills conducted.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
P287-705.28(d)(8) ? Fire Safety: Fire Drills
Corrective Action for the facility
Effective immediately upon identification of the deficiency during the licensing review, the facility ceased the use of elevators for evacuation during all fire drills. Any drills conducted since the date of notification have utilized stairwells and designated exit routes in compliance with fire safety regulations.
Systemic Changes to Prevent Recurrence
The facility's Fire Safety and Emergency Evacuation Policy have been revised to clearly state that elevators are strictly prohibited during fire drills and fire emergencies, without exception.
Approved evacuation routes were reposted throughout the facility, identifying fire exits only.
The fire drill documentation form was revised to include a required checklist item verifying that elevators were not used.
The facility's fire drill planning process was updated so that all drills are reviewed and approved in advance by facility management or the designated safety coordinator to ensure regulatory compliance.
Staff Training and Education
All staff received re‑education on fire safety procedures, including the prohibition of elevator use during fires and fire drills.
Training included:
Review of 705.28(d)(8)
Proper evacuation routes
Roles and responsibilities during fire drills
Training was completed via mandatory in‑service sessions.
New hires will receive this training during orientation.
Attendance records and training materials are maintained on file.
Monitoring and Ongoing Compliance
The facility administrator or designated safety officer will review 100% of fire drill documentation for the next 90 days to ensure elevators are not used.
Following this initial monitoring period, fire drill records will be reviewed quarterly as part of the facility's quality assurance process.
Any noncompliance identified will result in immediate corrective action and retraining.
Responsible Party:
Facility Administrator / Safety Coordinator |
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 project 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 an exception to the regulation requiring an audit if the project's gross income is less than $500,000 and provides a copy of their most recent tax return to the licensing representative. However, project staff did not provide a copy of their 2024 tax return as a condition of the exception approval. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
# 0169-79.25
Corrective Action to Prevent Recurrence
A written fiscal compliance procedure has been implemented to ensure compliance with § 709.25 audit and audit‑exception requirements.
A standardized licensure documentation checklist now includes mandatory verification of either:
Completion of an independent CPA audit; or
Qualification for the audit exception with submission of the most recent tax return.
Accountability for fiscal compliance has been assigned to the Program Director, who will ensure required documentation is submitted timely and retained.
Staff Training
Administrative and fiscal staff will be trained on § 709.25 fiscal management requirements, including audit standards and exception documentation, Training will be documented.
Monitoring
The director will conduct an annual review of gross income to determine audit or exception eligibility.
Fiscal compliance documentation will be reviewed prior to each licensure renewal.
Internal monitoring results will be maintained and reviewed by program leadership.
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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 ensure an annual written staff performance evaluation was completed, with copies being reviewed and signed by the employee, in two of three personnel records reviewed.Employee #1 was hired as the project director on January 1, 2023. There was no documentation in the personnel record indicating an annual written staff performance evaluation was completed as of the date of the inspection. Employee #2 was hired as the facility director on March 15, 2023. There was no documentation in the personnel record indicating an annual written staff performance evaluation was completed as of the date of the inspection. This is a repeat citation from the March 18, 2025 annual licensing renewal inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
0205-709.26(b)(3)
Correction of the Deficiency The facility corrected this deficiency as follows:
An annual written performance evaluation was completed for:
Employee #1 ? Project Director
Employee #2 ? Facility Director
Each evaluation was reviewed with the employee and signed by the employee and supervisor.
Copies of the completed and signed evaluations were placed in the employees' personnel records.
Plan to Prevent Recurrence The facility will prevent recurrence of this deficiency by implementing the following:
A personnel evaluation tracking log has been implemented to document hire dates and annual performance evaluation due dates for all staff.
Responsibility for tracking and ensuring completion of annual performance evaluations has been assigned to the Facility Director or designee.
Annual performance evaluations will be completed no later than the employee's anniversary date each year.
Personnel policies and procedures have been reviewed with administrative staff to ensure understanding of annual performance evaluation requirements, including employee review and signature.
3. Monitoring
The Facility Director or designee will conduct quarterly reviews of personnel records for twelve (12) months to verify that annual evaluations are completed, signed, and filed as required.
Monitoring results will be documented.
Any identified noncompliance will be corrected immediately. |
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
Based on a physical plant inspection, conducted at approximately 10:00am., the facility failed to ensure the project's hours of operation were displayed conspicuously to the general public.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
# 1917-709.94(b)
Corrective Action Taken
Immediately upon identification of the deficiency, signage clearly stating the project's hours of operation were created and posted at the main public entrance and reception area in a conspicuous location visible upon entry to the facility.
Systemic Changes to Prevent Recurrence
- A written policy was implemented requiring project hours of operation to be displayed prominently at all public entry points.
- Responsibility for compliance with signage requirements has been assigned to the Project Manager.
- A facility compliance checklist has been updated to include verification of posted hours of operation during monthly environmental and administrative reviews.
Monitoring and Ongoing Compliance
The Project Manager or designee will conduct monthly inspections to verify that hours of operation remain posted conspicuously and are accurate. Results of these reviews will be documented and maintained for a minimum of one year.
Responsible Person
Project Manager
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for not ensuring the project director/facility director completed at least 12 hours of annual training was submitted and approved by the Department for March 21, 2024 and March 18, 2025, annual licensing inspections. Failing to ensure completion of at least 12 hours of annual training for the project director/facility director was again found to be a deficiency during the March 11, 2026, annual licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
# A040-709.17(a)(3)
Corrective Action Taken (Immediate)
The Project Director/Facility Director will completed no fewer than 12 hours of required annual training.
Training certificates and documentation have been placed in the personnel file and are available for Department review.
Facility leadership was immediately notified that failure to meet annual training requirements constitutes a licensure risk.
Corrective Action Plan to Prevent Recurrence
1. Training Tracking System
The facility has implemented a formal training log that documents:
Required annual hours
Training topics
Completion dates
Verification signatures
The log will be maintained in the personnel file and reviewed quarterly.
2. Assigned Responsibility
The Compliance Officer/Administrator is now responsible for:
Tracking annual training requirements
Verifying completion no later than January 31 of each calendar year
Reporting compliance status to facility leadership
3. Deadline Enforcement
A standing internal deadline of January 31 has been established to ensure all required annual training is completed well in advance of licensing inspections.
Failure to meet this deadline will result in immediate corrective action.
4. Policy Revision
The facility has revised its personnel training policy to:
Clearly state annual training requirements
Define staff responsible for monitoring compliance
Include disciplinary measures for noncompliance
All supervisory staff have been trained on this revised policy.
Monitoring and Quality Assurance
Training compliance will be reviewed quarterly as part of the facility's internal compliance monitoring process.
Documentation will be reviewed annually prior to the licensing inspection.
Findings will be reported to leadership and corrective actions taken as needed.
Compliance Sustainability
Annual reminders will be issued at the beginning of each calendar year.
Training compliance will be included in annual performance evaluations.
Policies will be reviewed annually to ensure continued regulatory compliance.
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