INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 4/6/2011 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 May 5, 2011.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of staff records during the onsite inspection of 4/6/11, the facility failed to ensure that each employee received the required mandatory communicable disease training within the required timeframe.
The findings included:
The time frame for support staff to receive the required communicable disease training (TB/STD; HIV/AIDS) is two years from the hire date. Six support staff records were reviewed, three of these staff had hire dates exceeding two years at the time of the inspection on 4/6/2011. Three of three applicable staff failed to complete and document the required four hours of TB/ STD training within two years.
Volunteer employee # 3 began on 6/20/08 as support staff. There was no documentation of TB/STD training.
Volunteer employee # 5 began on 1/11/05 as support staff. There was no documentation of TB/STD training.
Volunteer employee # 6 began on 6/1/08 as support staff. There was no documentation of TB/STD training.
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Plan of Correction
We have scheduled the entire staff to be trained in STD/TB on June 8th. The American Red Cross will conduct the training. The training will be done at our facility. The Project Coordinator will be responsible to ensuring that all future staff members are adequately trained in a timely manner. |
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 a review of the physical plant during the onsite licensing inspection of 4/6/2011, the facility failed to ensure that each resident had a bed with a mattress that was in good repair.
The findings included:
During the onsite inspection nine apartments with at least three beds each were inspected. Spot checks of the condition of the mattresses in four resident apartments were conducted. Mattresses in three of the four rooms where spot checks were done were stained or worn.
Apartment #4 - was inspected on 4/6/2011 between approximately 4:30 and 5:00 P.M. A mattress in this apartment and noted to be worn and stained.
Apartment # 5- was inspected on 4/6/2011 between approximately 4:30 and 5:00 P.M. A mattress in this apartment and noted to be worn and stained.
Apartment # 11 - was inspected on 4/6/2011 between approximately 4:30 and 5:00 P.M. A mattress in this apartment and noted to be worn and stained.
The findings were reviewed with the Program Coordinator and the owner and were not disputed.
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Plan of Correction
We plan to buy four brand new mattresses to replace ones that are too worn/stained to be used. All other mattresses will be thoroughly cleaned and disinfected by the Facility Maintenance Director. In order to prevent further damage, we will put plastic "bed bug" covers on all of the mattresses in our facility. This will cover any stains that are currently there and prevent future ones. The Facility Maintenance Director will make sure that mattresses are covered and stay in good condition. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the review of the physical plant during the annual onsite licensing inspection, the facility failed to ensure that each bathroom is maintained in a clean, functional and sanitary manner at all times.
The findings included:
The general condition of the bathrooms in each apartment was poor. Bathroom fixtures were worn and stained. The heat duct vents in the bathrooms were dirty and had superficial rust on them. The ceiling tile in the bathrooms and other areas of each apartment were stained and or dingy in appearance. The tub caulking was poorly done and appeared to be in need of replacement in many bathrooms. Nine apartments were inspected on 4/6/11. Each had one bathroom for the use of three or four residents residing in that apartment.
Apartment # 4 - was inspected on 4/6//11 between approximately 4:30 and 5 P.M. Dirt and superficial rust was noted on the heating vents. Ceiling tile was dirty and discolored. Tub caulking was poorly done and needed to be replaced.
Apartment # 6 - was inspected on 4/6/11 between approximately 4:30 and 5 P.M. Dirt and superficial rust was noted on the heating vents. Ceiling tile was dirty and discolored. Tub caulking was poorly done and needed to be replaced.
Apartment # 9- was inspected on 4/6/11 between approximately 4:30 and 5 P.M. The tub and sink were badly stained. Dirt and superficial rust was noted on heating vents. Ceiling tile was dirty and discolored. Caulking was poorly done and needed to be replaced.
Apartment # 12 - was inspected on 4/6/11 between approximately 4:30 and 5 P.M. Dirt and superficial rust was noted on the heating vents. Ceiling tile was dirty and discolored. Tub caulking was poorly done and needed to be replaced. The light cover was broken.
The findings were reviewed with the owner and Program Coordinator and were not disputed. The management plan is to begin renovating the apartments. Some of this has occurred and new floor tile was noted in three apartments inspected.
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Plan of Correction
Tub calking will be replaced in Apartments 4, 6, 9 and 12. All heating vents throughout all the apartments have been cleaned, painted and/or replaced if necessary. Bathroom fixtures will be cleaned and revitalized. If they are beyond repair then they will be replaced. Ceiling tiles will be replaced or painted when severely stained. The Facility Maintenance Director will be responsible for maintaining each apartment in a clean and orderly fashion. |
705.7 (b) (4) 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:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on the physical plant inspection, the kitchen storage cabinets were noted to be dirty and the general level of cleanliness in the kitchen areas of each apartment was poor.
The findings included:
On 4/6/2011 a physical plant inspection of each of the nine apartments inhabited by the clients of the program were inspected between approximately 4:30 and 5:00 P.M. General observations of the overall cleanliness of each apartment was that overall cleanliness was poor. Ceiling tile were dirty and discolored and stained in many areas, floor coverings were worn and stained. Dirt and dust was observed in kitchen storage cabinets in each apartment.
Apartment # 6 was inspected on 4/6/11. The kitchen storage cabinets where pots and pans were stored were dirty and dusty.
Apartment # 7 was inspected on 4/6/11. The kitchen storage cabinets where pots and pans were stored were dirty and dusty.
Apartment # 8 was inspected on 4/6/11. The kitchen storage cabinets where pots and pans were stored were dirty and dusty.
The findings were pointed out to the owner and Project Coordinator during the inspection and were not disputed.
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Plan of Correction
Severely discolored or stained ceiling tiles will be painted or replaced. We are in the process of systematically replacing all worn and stained flooring with new ceramic tile. We have finished two apartments and hope to complete 2-5 more in the next six months. The kitchen storage cabinets have been thoroughly cleaned and new shelf lining has been put in place. The Facility Maintenance Director will be responsible for maintaining each apartment in a clean and orderly fashion. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on the review of the agency policy and procedure manual and other administrative materials presented for review and an interview with the Project Coordinator, the facility failed to document a performance report summarizing the progress toward meeting goals and objectives.
The findings included:
During the onsite licensing inspection of 4/6/2011, the facility policy and procedure manual and various other administrative materials were reviewed. There was no documentation of a progress report summarizing the goals and objectives for the past year at the time of the inspection. The Project Coordinator was asked if there was a performance report available for review and he indicated that there was none documented. The owner and the Project Coordinator did not dispute the findings.
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Plan of Correction
The Project Director has created a progress report summarizing the goals and objectives for the past year. The Project Director will also create a progress report summarizing this year's goals and objectives in November of each year. |
709.24(b) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(b) The project shall obtain written letters of agreement or understanding with primary referral sources.
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Observations
Based on the review of the facility policy and procedure manual and other administrative materials presented at the annual onsite licensing inspection of 4/ 6/ 2011, the facility failed to document letters of agreement with primary referral sources.
The findings included:
The facility policy and procedure manual and other administrative materials were reviewed on 4/6/2011. No documentation of letters of agreement were noted during the inspection. The annual goals and objectives documented that Crossing Over Apartments LLC has relationships with the local Salvation Army, First Valley Hospital and Pennsylvania Probation and Parole. During interviews with the owner and Project Coordinator these organizations were also mentioned as primary referral sources. No letters of agreement/understanding were documented for these entities. This issue was discussed with the Project Coordinator and owner and they did not dispute the findings.
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Plan of Correction
Crossing Over will obtain letters of agreement with primary referral sources within the next 30 days. The Project Coordinator will be responsible for maintaining letters of agreement with primary referral sources. |
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 fiscal documents presented at the time of the inspection and an interview with the Project Coordinator, the facility failed to document an annual audit of financial activities for the year ended 12/31/2010.
The findings included:
During the onsite licensing inspection conducted on 4/6/2011, the fiscal documents were reviewed. A letter from the agency accountant was documented on 4/1/11 stating that no income was documented for the last year. An attached tax return for 2010 showed the project claimed $0 income for the last year. The facility had requested an exception to the standard. A letter from the Department to the facility, dated 7/15/2010 and signed by the Division Director in response to a request for an exception, requested additional information. The Project Coordinator acknowledged that no additional documentation was forwarded to the Division subsequent to the 7/15/10 letter received. The facility failed to obtain an exception from the Department and failed to document the annual audit.
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Plan of Correction
A formal request for an exception to the standard has been sent to the Division. All additional information has been included with this request. We are waiting to hear the Division's decision whether the request is granted. If the request is denied we will attempt to provide alternative documentation. If that is unsuccessful we will obtain an audit. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records the facility failed to document the results of a reference investigation in six of six personnel records, as required.
The findings included:
During the onsite annual inspection held on 4/6/2011, six personnel records were reviewed. The facility policy and procedure stated that volunteers were subject to the same procedures as employees. Each personnel record was required to include documentation of reference checks.
Volunteer Employee # 1 was hired on 10/1/10. No reference checks were documented in his personnel record as of 4/6/2011.
Volunteer Employee #2 was hired on 6/1/10 . No reference checks were documented in his personnel record as of 4/6/2011.
Volunteer Employee #3 was hired on 6/20/08. No reference checks were documented in his personnel record as of 4/6/2011.
Volunteer Employee # 4 was hired on 8/14/09. No reference checks were documented in his personnel record as of 4/6/2011.
Volunteer Employee # 5 was hired on 1/11/05. No reference checks were documented in his personnel record as of 4/6/2011.
Volunteer Employee #6 was hired on 6/1/08. No reference checks were documented in his personnel record as of 4/6/2011.
The findings were reviewed with the Program Coordinator and Owner and were not disputed.
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Plan of Correction
We will amend the facility's policy and procedure to indicate that employees no longer need to be in recovery. Instead employees will meet the minimal requirements outlined in each position's description. Reference checks will be done to make sure these requirements are met. The Project Coordinator will be responsible for performing reference checks. |
709.71(b)(2)(iv) LICENSURE Orientation/Services provided
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but not be limited to a familiarization with:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to provide accurate orientation regarding client confidentiality in drug and alcohol treatment facilities in Pennsylvania. Information provided to clients during orientation relative to 4 Pa. Code subsection 255.5 was incorrect in five of five client records.
The findings included:
Five client records were reviewed on April 6, 2011. Documentation in each client record reviewed misinformed clients regarding confidentiality protections at 4 Pa. Code subsection 255.5 by stating that client identifying information could be released to judges and probation and parol officers without the client's written consent. State law at 71 P.S. subsection 1690.108 (b) requires the client's written consent prior to the release of any client identifying information. Federal regulations at 42 CFR Part 2, Subpart C, subsection 2.35 (a)(2) require the client's written consent prior to the release of information to elements of the criminal justice system.
Client Record # 1 - This individual was admitted on 10/16/10. The confidentiality form signed at the time of intake incorrectly informed the client that information from the record could be released without consent to judges and probation and parole officers.
Client Record # 2 - This individual was admitted on 1/29/11. The confidentiality form signed at the time of intake incorrectly informed the client that information from the record could be released without consent to judges and probation and parole officers.
Client Record # 3 - This individual was admitted on 10/9/09. The confidentiality form signed at the time of intake incorrectly informed the client that information from the record could be released without consent to judges and probation and parole officers.
Client Record # 4 - This individual was admitted on 1/6/11. The confidentiality form signed at the time of intake incorrectly informed the client that information from the record could be released without consent to judges and probation and parole officers.
Client Record # 5 - This individual was admitted on 2/12/10. The confidentiality form signed at the time of intake incorrectly informed the client that information from the record could be released without consent to judges and probation and parole officers.
The findings were reviewed with the owner/governing body and the project Coordinator and were not disputed.
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Plan of Correction
We have corrected the confidentiality protections of 4 Pa. Code subsection 255.5 by eliminating the words "or without" everywhere they are referenced. All clients will now use the updated form of 4 Pa. Code subsection 255.5. The Project Coordinator will be responsible for verifying that all clients use the updated form. |
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.
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Observations
Based on the review of client records, the facility failed to document activity notes which tracked the client's progress and current status in meeting his goals or needs during residency. The agency also failed to adhere to its own policy on documentation.
The findings included:
Five client records were reviewed during the annual onsite licensing inspection on 4/6/11. Each record was required to document activity notes which tracked the client's progress and status on meeting his goals or needs during residency.
Facility policy 709.71(a)(2) on page 48 of the manual addressed the completion of residency and stated that completion would be determined by "...Joint agreement between the resident and Crossing Over staff upon review of personal goal achievement in the areas inclusive of but not limited to: employment. financial independence, recovery and interpersonal relationships. Although goal and objective identification is individualized by and for each resident, the facility wide standard for goal achievement is as follows: Employment must be maintained throughout the entire length of residency; Financial independence must be displayed ( proof by financial record review) by the third month of residency and maintained until completion; Recovery must be maintained for the entire length of residency and interpersonal relationships must show improvement throughout stay as evidenced by increased contact with family and/or reduced conflicts with family."
The general observation made in five of five records reviewed was that the facility failed to implement its own policy in regard to the development of individualized personal goals for each client served. In addition , the facility failed to document progress on the required goals stipulated in the above policy for each client to meet prior to a successful completion of the program. Activity notes were sporadic at best and note content did not specifically address each of the stated required goals for each client or track achievement.
Record # 1- The client was admitted on 10/16/10. Documentation of activity notes dated 11/2/10, 12/12/10 and 2/14/11 were included in the record. Activity note content did not address the mandatory stated goals described in the facility policy and procedure. Facility policy was not followed in regard to developing individualized goals.
Record # 2- The client was admitted on 1/29/11. Documentation of activity notes dated 2/2/11 and 2/26/11 were included in the record. Activity note content did not address the mandatory stated goals described in the facility policy and procedure. Facility policy was not followed in regard to developing individualized goals.
Record # 3 - The client was admitted on 10/9/09. Documentation of activity notes dated 1/5/10, 5/7/10,10/19/10, 1/12/11 and 3/5/11 were included in the record. Activity note content did not address the mandatory stated goals described in the facility policy and procedure. Facility policy was not followed in regard to developing individualized goals.
Record # 4 - This client was admitted on 1/16/11. Documentation of activity notes dated 1/23/11, 2/12/11 were included in the record. Activity note content did not address the mandatory stated goals described in the facility policy and procedure. Facility policy was not followed in regard to developing individualized goals.
Record # 5- Client was admitted on 2/12/10. Documentation of activity notes dated 3/27/10 4/12/10, 7/15/10, 11/5/10 were included in the record. Activity note content did not address the mandatory stated goals described in the facility policy and procedure. Facility policy was not followed in regard to developing individualized goals.
The findings were reviewed with the Program Coordinator and the owner/governing body and were not disputed.
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Plan of Correction
Managers will have weekly meetings with each client to establish and review their personal goals. A brief report of each of these meetings will be placed in the client's folder. The Project Coordinator will review these reports on a weekly basis. |