INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on November 5, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Crossing Over Apartments, LLC 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 and a plan of correction is due on December 20, 2007. Since this was the initial inspection conducted, not all regulations were reviewed. During future inspections, all regulations will be reviewed for compliance.
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection conducted on November 5, 2007, the facility failed to keep the rear exit safe and in good repair. The rear exit route had a metal plate covering a hole in the concrete walkway that goes over the steps down to the basement.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on the physical plant inspection conducted on November 5, 2007, the facility failed to provide a solid foundation for the bed in apartment #7/bedroom #1. A mattress and a box-spring were placed on the floor with no foundation. Additionally, the facility failed to provide documentation that the mattresses were fire retardant.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
Based on a physical plant inspection conducted on November 5, 2007, the facility failed to provide dresser drawers that were intact in apartment number/bedroom number: #5/1, #6/1 and #10/1.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.5 (h) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(h) Each bedroom shall be ventilated by operable windows or have mechanical ventilation.
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Observations
Based on the physical plant inspection conducted on November 5, 2007, the facility failed to have bedrooms ventilated by operable windows or mechanical ventilation. Windows were painted shut and were not operable in apartment #5, bedroom #1, apartment #6, bedroom #1 and 2, and apartment #9, bedroom #2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on the physical plant inspection conducted on November 5, 2007, the facility failed have either an operable exhaust fan or window for ventilation in one of two single occupancy bathrooms on the first floor near the day room.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on the physical plant inspection conducted on November 5, 2007, the facility failed to provide thermometers to ensure proper food temperature of refrigerator and frozen foods in the following apartment kitchens: #3, 4, 5, 6, 7, 8, 9, 10, 11 and 12.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based on the physical plant inspection conducted on November 5, 2007, the facility failed to maintain smoke detectors that were within 15 feet of each bedroom door in the following apartment number/bedroom number: #4/3, #5/4, #6/4, #9/3, #10/4, #11/4 and #12/4. Additionally, the smoke detector that was within 15 feet of the bedrooms in apartment #8 was not interconnected with the rest of the detection devices.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on the physical plant inspection conducted on November 5, 2007, the facility failed to designate a bedroom equipped with a detection device for the hearing impaired.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential 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
Based on the physical plant inspection conducted on November 5, 2007, the facility failed to document that the fire extinguishers were inspected and approved by the local fire department or fire extinguisher company.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on the physical plant inspection conducted on November 5, 2007, the facility failed to ensure confidentiality of client identity. Large windows in the first floor resident day room were not covered.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |