INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2, 2008 through June 3, 2008 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 July 3, 2008.
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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 overall training plan for the 2008 training year, the facility failed to document the trainers and proposed dates of training for the training subjects identified.
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Plan of Correction
The Project Director has identified and included in the Facility overall 2008 training plan the proposed dates,types of training to be conducted and proposed trainers for each training. The Facility Training Plan for calender year 2008 has been revised as of July 1, 2008 to reflect these additions. |
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.
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Observations
Based on a review of personnel and training records, the facility failed to document an individual training plan in one of one record reviewed, #1.
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Plan of Correction
The Project Director has documented the individual training plan as identified in the deficiency report. Copies of training certificates, a log of trainings and training evaluations have been included in the record.
The Project Director will review the training file with each "staff" member on an annual basis, consistent with their date of hire. Each employee training file will be updated/revised annually. Training logs, evaluations and copies of certificates will be included in each training file. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of the staffing schedule and CPR certifications/First Aid training documents, the facility failed to provide sufficient number of staff persons so that at least one person trained in these skills were onsite during all hours of operation. There were no staff certified in CPR and trained in first aid on site during the following dates and times: 7:00 AM-5:00 PM on May 10, 17, 24, 31 and June 1, 2008; 5:00 PM-11:00 PM on May 5-June 1, 2008; 11:00 PM-7:00 AM on May 9, 10, 15, 16, 23, 24, 29 and 30.
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Plan of Correction
Two(2)assistant managers received 1st Aid/CPR training by the Red Cross on 6-7-08. Six(6)other staff volunteers are scheduled for 1st Aid/CPR training at the local American Red Cross center on 7-11-08. As of 6-7-08 there has been a 1st Aid/CPR-certified "staff" member on duty 24 hours/day in the facility. All "staff" will be re-certified in 1st Aid/CPR when required. The Project Director and/or Facility Coordinator
will review staffing compliance on a daily basis. The Project Director will review "staff" certifications on a semi-annual basis to ensure compliance of 24/7 CPR/First Aid "coverage". |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, the facility failed to install slip-resistant surfaces in bathtubs and showers for the following apartment numbers, 4, 5, 7, 8, 9, 10, 11, 12 and 13.
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Plan of Correction
Facility maintenance workers have installed "slip-resistant" materials in all bathtubs and showers as of 6-10-08. Slip-resistant materials will be monitored and replaced by maintenance workers when found defective or missing. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill record, the facility failed to document a complete record. The fire drill record did not include the amount of time it took to evacuate the building, the exit route used, the number of persons in the facility at the time of the drill and whether the fire alarm or smoke detector was operative.
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Plan of Correction
Facility fire drill records have been revised by facility staff and reviewed/approved by the Project Director to include all documentation noted in the deficiency report. Revised forms have been effective as of 6-4-08. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to document that alternative exit routes were used during the fire drills for February, March, April and May 2008.
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Plan of Correction
As of 6-4-08 fire drill records have been revised by facility staff and reviewed/approved by the Project Director to document when and which alternative exit routes are used for any/all fire drills. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the fire drill record, the facility failed to document that either a fire alarm or a smoke detector was set off during each fire drill in February, March, April and May 2008.
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Plan of Correction
As of 6-4-08, fire drill records have been revised by facility staff and reviewed/approved by the Project Director to document which type of alarms are activated for any/all fire drills. |
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, the facility failed to obtain informed and voluntary consents in two of two records reviewed, #2 and 4. According to activity notes, the facility contacted client #2's parole officer on 4/3/08 and 4/15/08 to relay client-related information, but there was no consent to release information signed by the client for their parole officer. According to an activity note on 4/28/08, the facility contacted client #4's parole officer on 4/28/08 to relay client-related information, but there was no consent to release information for the client's parole officer.
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Plan of Correction
As of 7-1-08, all staff have been trained by the Project Director in the completion of Consent for Release forms.Consent for Release forms will be completed in their entirety(including dates and signatures of staff and residents)for any information needing to be released/obtained to/from any outside person/entity on behalf of all residents. The Project Director and/or Facility Coordinator will review resident records monthly or as developments change in the residents status. All new "staff" will be trained regarding compliance of all consent forms completion at time of orientation. All present "staff" will be re-trained, either when standards change or on a semi-annual basis. |
709.71(b)(3) LICENSURE Basic Personal data
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Basic personal data.
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Observations
Based on a review of resident records, the facility failed to document complete basic personal data in two of four records reviewed, #1 and 4. The personal data form had questions left unanswered in the client's employment section and recreational/leisure section in record #1. The personal data form had questions left unanswered in the legal and educational sections in record #2. The personal data form did not have a section to document the client's sexual history.
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Plan of Correction
As of 7-1-08, all "staff" responsible for "intakes" have been trained by the Project Director to fully complete the intake forms/questionnaires. It is required that no question remains unanswered and that no blanks should exist in the intake forms. No response is to be limited to simple "yes or no".
All new "staff" members will receive training in this area at time of orientation. The Project Director and/or Facility Director will review all intakes. Review will be documented by signature and dating. Any deficiencies will be corrected immediately. |
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 client records, the facility failed to document complete medication records in two of two records reviewed, #1 and 2. The medication record did not include the dosage and frequency of the medications that the client was on in record #1. The client signed a "hold harmless agreement" which stated that the program would be the custodian of the client's medication but that he would still be responsible for obtaining the medication from staff when it was time and self-administering it in client record #2. The facility failed to keep a medication record that included the client name, type of medication, amount, time and date, and staff signature.
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Plan of Correction
The Project Director has revised the resident medication records to include specific information including name of resident, type of medication(s),
dosage(s), frequency of dose, time/date of dose taken and staff signature. This revision has taken effect as of 7-1-08. All "staff" will be trained by the Project Director by 7-11-08 relative to properly documenting the medication records. The Project Director and/or the Facility Coordinator will review resident medication records monthly. All "staff" will be trained by the Project Director on proper documentation of resident medication records by 7-11-08. All new "staff" will be trained for medication record documentation by the Project Director at time of orientation. |