INITIAL COMMENTS
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A follow-up survey conducted on February 17, 2009 found that Crossing Over Apartments, LLC had not corrected the following deficiencies cited under 28 PA Code with the applicable chapters which pertain to the facility. The deficiencies were cited as a result of a licensing survey completed on June 3, 2008. Plans of correction are due by March 23, 2009.
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Plan of Correction
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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility procedure manual and an interview with the facility director the agency failed to document an overall training plan for calender year 2008 or 2009.
Findings:
Based on an interview with the facility director on February 17, 2009 and a review of the procedures manual the facility did not establish an overall training plan to address training needs for calender year 2008 or calender year 2009.
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Plan of Correction
The Project Director has identified and included in the facility overall 2008 and 2009 training plan the proposed dates, types of training to be conducted and proposed trainers for each training. This has been accomplished as of 3/22/09. |
709.72(a)(3) LICENSURE Medication records
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:
(3) Medication records.
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Observations
Based on a review of four client records, the facility failed to document medication records in two of four client records.
Findings:
Four client records were reviewed on February 17, 2009. Two of the four client records documented the residents utilized medications.
Client record #1 - Admitted on October 23, 2008. Client record # 1 did not document the dose or frequency of use.
Client record # 2 - Admitted on January 22, 2009. Client record # 2 did not document the dose or frequency of use of the medications.
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Plan of Correction
Made changes to client medication document to include dosage and frequency.
Put new documents into use as of 2/19/09. |