D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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JAMES A. CASEY HOUSE, LLC
199-207 SOUTH MAIN STREET
WILKES BARRE, PA 18701

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Survey conducted on 02/16/2012

INITIAL COMMENTS
This report is a result of an unannounced Plan of correction inspection conducted on February 16, 2012 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.	Plan of Correction
704.11(b)(1) LICENSURE Individual training plan. 704.11. Staff development program. (b) Individual training plan. (1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
Observations Based on a review of staff training records, the facility failed to ensure that an individual training plan was documented for each employee on an annual basis. The findings include: Five employee records were reviewed during the unannounced onsite inspection conducted on 2/16/2012. The plan of correction from the 8/9/2011 licensing inspection for this deficiency stated that all employees would receive updated individual training plans in November of 2011. Four of five records reviewed had individual training plans documented on 11/18/2011. There was no updated individual training plan documented for employee # 5. Employee # 5 was hired in March of 2005 and placed in the position of Project Director in October of 2010. The last documentation of an individual training plan on file for this employee was 10/10/2010. The findings were reviewed with the owner and Project Coordinator of the program and were not disputed.	Plan of Correction An individual training plan has been developed for the Project Director and will be placed in their folder. The record will be updated in November 2012. The Project Coordinator will be responsible for ensuring that all employees have updated individual training plans.
709.72(a)(5) LICENSURE Activity Notes 709.72. 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: (5) Activity notes.
Observations Based on a review of client records, the facility failed to ensure that each activity note was dated and signed by the individual making the entry. The findings include: During the unannounced onsite inspection of 2/26/2012 six client records were reviewed. Five of six client records reviewed failed to include documentation of signatures on each of the activity notes documented in the record. Client record # 1 - The client was admitted on 7/15/11. Activity notes on the following dates did not include the signature of the individual making the entry: July 24, 29; August 3, 11, 18, 26; September 4, 13, 22, 29; October 8. All entries were from 2011, there were no activity notes documented for 2012. Client record # 2 - The client was admitted on 2/4/10. Activity notes on the following dates did not include the signature of the individual making the entry: March 15; June 22, 24; July 1,8,15,22,29; June 12; August 6, 15, 23; September 1, 10, 18, 26; October 4, 12 all entries are from 2011, there were no activity notes documented for 2012. Client record # 3 - The client was admitted on 6/2/11. Activity notes on the following dates did not include the signature of the individual making the entry: July 1, 8, 15, 22, 29; August 7, 14, 23; September 2, 11, 19; October 7, 15, 20. Client record # 4 - The client was admitted on 12/13/10. Activity notes on the following dates did not include the signature of the individual making the entry: January 7; June 23, 30; July 7, 14, 21, 28; August 4, 13, 21, 29; September 8, 12, 27 ; October 5, 13, and 20. All entries are from 2011, there were no activity notes documented for 2012. Client record # 5- The client was admitted on 7/27/11. Activity notes on the following dates did not include the signature of the individual making the entry: September 16, 25; October 2, 10, and 20. All entries are from 2011, there were no activity notes documented for 2012. The findings were reviewed with the owner and the Project Coordinator and were not disputed.	Plan of Correction All client activity notes will now include the signature of the individual making the entry. The Project Coordinator will be responsible for client activity notes.