INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 21, 2024, 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(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 three personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the project director.
Employee # 1 was hired as Project Director on January 1, 2023 and has remained in that position. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. Employee # 1's employee record only documented 4.25 hours of training for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Observation #: 0075
ERC's Staff development training program:
The Project Director signed up for DDAP training website on Friday March 22, 2024, because his training in 2023 did not meet DDAP requirements for HIV/AIDS and TB/STD training. The Project Director will take at least 12 hours a year or more on the following forementioned DDAP training, one being HIV/AIDS and TB/STD training, etc. The project Director will also take some outside training that may be relevant to his position starting as of 03/28/2024. These training will also be recorded on the project director training log. The facility director will check 3 months before the training year ends to ensure that the project director has completed at least 12 hours of DDAP drug and alcohol required training by reviewing training taken and training logs for the project director within the last 9 months. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on March 21, 2024, the facility failed to ensure that exits from the nonresidential facility were unobstructed, as the emergency exit door from the rear stairwell of the building was obstructed by three ladders being propped against the door. The door was unable to be opened from the inside. Additionally, the exit door led to a small, gated area that was locked and could not be exited to get to the safe meeting location.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (a) (1) (i) LICENSURE
Fire safety.:
Tag P239: Obstructed exit
On March 22, 2024, ERC asked the building supervisor to tell them when contractors are working outside or inside of all fire exits, so that ERC can ask for a waiver from the department of DDAP until the work has been completed. ERC cleared all fire exit doors and made sure all locks on the gate would not interfere with opening the gate up on Sunday March 24, 2024. ERC posted a sign on the fire exit door from the fire escape stating to lift the gate handle to exit. The posting of the sign will be completed on 03/27/2024.
The Project Director will:
Post a sign on the fire exit door leading to the fire exit and post another sign at the bottom of the fire escape that exits the building from the ascending stairwell. The sign will read please lift gate handle and then exit from the yard
Both signs will be replaced as needed
ERC will let all its clients and staff members know how to operate the gate during admissions, intakes, orientations, supervisions, and staff meetings
ERC will also send out emails letting all staff members know how to exit the gate from the yard
ERC will also poster a sign in the common area of the facility for all to see that enters ERC
ERC will also practice these steps during fire drill training
ERC will also recommend to the building supervisor to have a panic bar placed or installed on the gate.
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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
Based on a physical plant inspection on March 21, 2024, the facility failed to ensure interior exits were lit at all times.
The light in the vestibule connecting the hallway to the emergency exit stairwell was not lit and the area was pitch black when the doors were closed.
This is a repeat citation from the April 17, 2023 and March 23, 2022 annual licensing renewal inspections.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.28 (a) (1) LICENSURE
Fire safety.: (a) Exits. (1) The nonresidential facility shall: (v) Light interior exits and stairs at all times.
P247-
ERC facility director has been inspecting the lights in the fire exit biweekly and monthly. A fire exit log was created to show the date of inspection and if the lights were working or not working. However, when the lights were last inspected on 3/15/2024, they were working. ERC has asked the building supervisor if he could let ERC know when contracts are working in the building, so that ERC or he could check to see if the fire escape lights are still lit and that the contracts have either move their tools out of the ascending area and or fire exit doors. However, on 03/21/2024, the lights were out. Therefore, ERC installed two new lights so that this will not happen again. One light was installed in the ceiling and another right above the fire exit sign. A picture was sent to the auditor to show the correction, on 03/25/2024.
ERC- ERC executive director will do a monthly inspection of the fire exit vestibule once a month to see if the newly installed lights are still lit. If either one of the lights is out the executive director will:
First try to see if the light bulbs need to be replaced and if either light needs to be replaced. The executive director will purchase light bulbs to replace.
Call the onsite supervisor to see if any work is being done in the building and ask why this room is not being kept well lit.
If the building supervisor is not present the executive director will call the electrician who installed these lights in the fire exit to come back out and make any repairs within 24-48 hours.
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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 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director:
§ 709.23.
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ERC: Board of Directors will meet with the project director 3 months before the program policies and procedural manual are to be signed on. The Board of Director will also send an email alert to the project director and the facility director one month before the year end of the program policies and procedures manual due date as a reminder for the project director to signed-off-on the policies and procedural manual. A sign-off sheet for the program policies and procedures manual will also be placed in the project director's office, where it can easily be seen daily starting on 3/28/2024.
This deficiency will be corrected by:
The project director will meet with the Board of Directors 3 months before the signing off on the policies and procedural manual which are to be signed off yearly.
A follow-up email will be sent by the Board of Directors to the project director again in another month.
Then an email will be sent to the project director and the facility director by the Board of Directors as a reminder one month before the signing of the policies and procedural manual due date.
The Project Director and the facility director will discuss policies and procedures during their supervision and staff meetings.
And by high lighting the posted sign-off- sheet in the project director's office and the facility director's office.
The project director will sign an attestation each time there are supervision meetings updating the policies and procedural manual to show that the policies and procedural manual has been reviewed and updated. |
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 physical plant inspection, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring that exits were lit at all times was submitted and approved by the Department for the April 17, 2023 and March 23, 2022 annual licensing inspections. Ensuring exits were lit at all times was again found to be a deficiency in the March 21, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Observations #: A040
The ERC's project director, facility director, and the board of directors will be responsible for the overall sight and monitoring of the plans of corrections.
1. The project director will review all plans of corrections on a quarterly basis.
2. The project director will create a review team that will review the plans of corrections every six months and then report back to the project director any parts of the plans of corrections that are not being implemented.
3. The project director will call a mandatory meeting when necessary to explain the importance of carrying out the plans of corrections and then show the staff how to implement the plans of corrections
4. The facility director in the absence of the project director will monitor the plans of corrections at their staff meetings and supervision meetings
5. The facility director will designate one staff member to monitor the lights in the fire exit and one staff to monitor the locks on the gate that you must exit from
6. The facility director will meet once monthly with his team and will keep a log of when he has met and reviewed the plans of corrections with his team
7. The board of directors will meet twice a year with the project director to see if the plans of corrections are still being carried out
8. The board of directors will request documents from the project director and the facility director on plans of corrections implementations every six months
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