INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 2009 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 12, 2009.
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Plan of Correction
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility manual and an interview with the project director, the project director failed to review and sign off on the facility manual in the last twelve months.
The findings include:
A review of the policy and procedure manual was completed on April 23, 2009. There was no documentation of the project director's dated signature indicating the manual had been updated over the last twelve months. The project director was interviewed on April 23, 3009 and he confirmed that he had neglected to update the facility policy and procedure manual.
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Plan of Correction
The Project Director will immediately review the Project Manual and update all policies and procedures that required changes during the past twelve months effective this date. A document wil be signed and dated by the Project Director indicating the review was completed and all changes so noted in the manual. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of the facility policy and procedure manual, personnel records and an interview with the facility project director, the facility failed to document the employee's and supervisor's signatures on the written job descriptions.
The findings include:
The facility policy and procedure manual and the facility's personnel records were reviewed on April 23, 2009. There was no documentation of the employees' and supervisor's signatures on the written job descriptions. The project director was interviewed on April 23, 2009 and he confirmed that he did not obtain the employees' signatures and that he neglected to counter sign the job descriptions.
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Plan of Correction
Effective immediately, all employee and supervisor signatures will be provided on the respective written job descriptions. Where any job description deficiencies are noted in the Project Directors' review of the employee files, the deficiencies will be immediately corrected. |
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
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Observations
Based on a review of the facility manual, the personnel records and an interview with the project director, the project director failed to include the requisite skills, knowledge and experience on the written job descriptions.
The findings include:
A review of the policy and procedure manual and the client records was completed on April 23, 2009. The written job descriptions did not include the requisite skills, knowledge and experience. The project director was interviewed on April 23, 3009 and he confirmed that he had neglected to include the requisite skills, knowledge and experience on the written job descriptions.
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Plan of Correction
Effective immediately, the Project Director will develop and complete a comprehensive job description for all employees that will include the job title, tasks and responsibilities of the job and minimum requirements of the requisite skills, knowledge and experience for that position. The job descriptions will be signed and dated by the employee and the Project Director. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records and interviews with the project/facility director and a resident manager, the facility failed to obtain written consents to release information regarding releases to probation/parole officers in two of two client records.
The findings include:
Eight client records were reviewed on April 23, 2009. Two client records documented releases of client identifying information to probation and parole officers, where there was no documentation of the client's written consent to permit the releases of information.
A release of information from client record # 2 was documented in the 1/16/09 activity note. The release of information was made to the client's probation officer. There was no documentation of the client's written consent to permit the release of that information. An interview with the project/facility director and the resident manager on 4/23/09 provided confirmation that a written consent to release the information had not been obtained.
A release of information from client record # 4 was documented in the 3/18/09 activity note. The release of information was made to the Drug Court and the client's probation officer. There was no documentation of the client's written consent to permit the release of that information. An interview with the project/facility director and the resident manager on 4/23/09 provided confirmation that a written consent to release the information had not been obtained.
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Plan of Correction
Effective immediately, staff will, during the initial intake interview and at other times when deemed necessary, have residents sign a "Consent for Release of Information" form for any outside person or entity that requires or requests information relative to any resident. These consent forms will pertain to family, employers, probation/parole officers, judges, doctors or other persons the resident wishes to acknowledge. The "Consent for Release of Information" form has already been changed to reflect this standard. The resident records noted in this deficiency have had the required consent forms signed, dated and placed in the records. |