INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 5, 2016 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of administrative information, the facility failed to provide documentation that the project/facility director meet the qualifications for the project/facility director position.
The findings include.
During the inspection on February 5, 2016 employee # 1's educational and experiential qualifications were requested by this licensing specialist. The facility failed to provide employee's #1's personnel record for review. Employee #1 was hired on July 1, 2015.
These findings were reviewed with facility staff during licensing process.
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Plan of Correction
Employee number #1 resume and degree was faxed to specialist on February 8, and personal record is at the facility that contain this information. Facility director is responsible for correcting this information. Personnel record was put at the facility on March 1st. Director is responsible for ensuring that personnel file are up to date and kept at facility. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of administrative information the facility failed to provide a sufficient number of staff persons with CPR certification and First aid training.
The findings include:
An inspection was completed on February 5, 2016. The facility was unable to provide documentation that staff had CPR/First aid certification. The facilities hours of operation are Monday through Friday 12 pm-4 pm and evenings by appointment only.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director faxed CPR/Fist Aid certification to licensing specialist on 2/8/2016. Director is responsible for keeping the CPR/First Aid certification in the personnel file. CPR/First Aid expires 4/2017. Director is responsible for ensuring that staff CPR/First Aid certification is current at all times. CPR/First Aid certification was placed into employee #1 personnel file. |
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
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of a fire extinguisher upon staff employment in one of two personnel records reviewed.
The findings include:
Two personnel records were reviewed on February 5, 2016, one of which was for newly hired staff. The facility failed to document the completion of fire extinguisher training upon employment in personnel record #1.
Employee #1 was hired on July 1, 2015. The training was not documented at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee number #1 received fire extinguisher training on 3/15/16. Director is responsible for ensuring that newly hired staff is given fire extinguisher training upon hire during orientation. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation, the project failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative documentation records were reviewed on February 5, 2016.
The facility has an exception to the Department of Drug and Alcohol Program's General Standards for Free-Standing Treatment Activities, Chapter 709.25 (a), relative to an independent annual audit of financial activities associated with the project's drug/alcohol abuse services. However, the exception states: " In lieu of the annual audit, a certified public accountant will review the bank statements and complete the corporation's tax return. In addition, all financial reports including bank statements, payroll and staffing records and annual tax returns will be available for Division review during on-site licensing inspections."
The facility failed to provide documentation that a certified public accountant completed the corporation's tax return for the 2014 Fiscal Year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A CPA will be retained on April 27, 2016 to complete the financial audit for 2014-2015 and the tax returns. This will be completed by May 1, 2016. The CPA will be on retainer for future financial audits to prevent this from happening again. The president of the board of directors is responsible for insuring that a financial audit is completed annually. |
709.26(b) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
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Observations
Based on a review of administrative information, the facility failed to provide a personnel record.
The findings include.
Personnel record for Employee #1 was requested for review by the licensing specialist on February 5, 2016. As of the date of the licensing inspection, the facility failed to provide employee # 1's personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1 personnel record is onsite at the facility. Employee #1 personnel record contain, resume, degree, job description, application, CPR/First Aid certification and has been placed at the facility on March 1st. Director is responsible for ensuring newly hired employees are given personal records that contain this information upon hire |
709.17(a)(1) 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:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on a review of administrative documentation, the facility failed to comply with the directive issued by the Department requiring the facility to develop and implement policies and procedures for the reporting of unusual incidents.
The findings include:
As per the directive within Chapter 709 Subchapter C enacted on 10/18/2014, the facility was required to develop and implement policies and procedures for the reporting of unusual incidents. The facility's administrative records were reviewed for documentation of policies and procedures for the reporting of unusual incidents on February 5, 2016. As of the date of the inspection, the facility has not developed policies and procedures for the reporting of unusual incidents.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director developed the Reporting of Unusual Policy Incidents Chapter 709.34 and placed policy in the facility manual on 2/28/2016. The facility will follow the policies and procedures for reporting of unusual incidents and let the department of drug and alcohol know within 3 days. Director is responsible for training the staff on the policies and procedures and will let the staff know about reporting at time of hire during new staff orientation. |