INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3, 2010 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 June 5, 2010.
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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 survey results and interview with facility staff the project failed to establish an overall plan to address staff training needs.
Findings:
Project staff development procedures require an annual staff development plan be established. A review of the staff development manual, facility files and an interview with the facility director on June 3, 2010 confirmed that the facility failed to document an overall staff development plan for calender year 2010.
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Plan of Correction
An annual facility staff development plan, including name/type training; proposed trainer and proposed date of training will be established by the Facility Director by July 1, 2010 and will include topics of training mentioned in the staffs' Individual Training Plans.
This annual plan will be reviewed and evaluated each November. A new annual staff development plan will be completed in December of each year. |
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 survey results and staff interviews, the facility failed to develop annual individual training plans.
Findings:
A review of staff development records and an interview with the facility director on June 3, 2010 confirmed that the facility failed to document annual individualized staff training plans. Five of five staff development records documented individualized plans established in July 2008. Individualized plans have not been established or documented for the 2010 training year.
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Plan of Correction
By July 1, 2010 and in October of each subsequent year, Individual Training Plans will be completed upon review of the prior years staff training. The Facility Director will meet with each staff member in October to discuss their individual training needs for the next year.
Each staff member will be offered an opportunity to request topics and/or types of training consistent with their position, educational background, abilities and personal interests. |
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 survey results and staff interviews the facility failed to meet the general training requirements.
Findings: Five staff development records were reviewed on June 3, 2010 Two of the five records were required to document HIV and TB training within two years of employment.
Staff record # 3. Hired on June 1, 2008. No documentation of the general training requirements were in the record. An interview with the facility director on June 3. 2010 confirmed that the facility failed to provide verification of the general training requirements.
Staff record # 5. Hired on May 1, 2008. No documentation of the general training requirements were in the record. An interview with the facility director on June 3. 2010 confirmed that the facility failed to provide verification of the general training requirements.
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Plan of Correction
Official copies of HIV/TB and STD training certificates were obtained and placed into the records of employees #3 and #5 on june 10, 2010. The training was provided on May 18, 2009 by Certified Instructor Sharon Whitebread of the the American Red Cross. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on survey results, fire drill log and staff interviews, the residential facility failed to conduct a fire drill during sleeping hours every six months.
Findings:
The fire drill log book reviewed on June 3, 2010 provided documentation on monthly fire drills. The last sleeping hour fire drill was completed on September 9,2009. A sleeping hour drill needed to be completed by March 3, 2010.
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Plan of Correction
A fire drill during sleeping hours is scheduled for June 18, 2010 at 11:30PM.
The Facility Coordinator will be responsible for conducting, administering and documenting the fire drill.
All future fire drills will be conducted in the manner described in facility policies and will meet standards for times of day to conduct those fire drills. |
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 an interview with the Project/Facility Director and the Project owner, the facility failed to complete an audit for fiscal year 2008.
Findings:
The Project/Facility Director and the Project owner stated that there was no profit, but sever losses for the last two fiscal years. They confirmed on June 3, 2010 that audits were not completed for this LLC company.
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Plan of Correction
The facility is submitting to BDAP a request for an exception to Standard 709.25 as of June 11, 2010. This exception request is being submitted due to the lack of any fiscal operations within the Crossing Over Transitional Living Facility since its' first day of licensure. |
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 survey results, review of client records and staff interviews, the project failed to document a complete record that includes client medications.
Findings:
Six client records were reviewed on June 3, 2010. Five of the six records included documentation of client medications. Four of five records did not include documentation of the frequency and dose of medications used.
Client records # 2, 4, 5, and 6 included documentation of medications but failed to include documentation of the dose and frequency of use.
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Plan of Correction
The Facility Coordinator, on June 4, 2010 obtained and recorded the frequency and dosages of medications for clients #2,#4, #5, and #6. The Facility Coordinator has instructed and trained all managers and assistant managers to document this information at time of initial intake or when medication information dictates a change. The Facility Coordinator will be responsible for reviewing each client file on monthly basis. |
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 survey findings, client records review and staff interviews, the project failed to document client activity notes.
Findings:
Six active client records were reviewed on June 3, 2020. Three of six records failed to document client activity notes.
Record review # 1 - Admitted on August 21, 2009. The last activity note in record review #1 was entered on October 8, 2009.
Record review # 2- Admitted on July 6 2009. The last activity note in record review #2 was entered on October 31, 2009.
Record review # 3 - Admitted on June 22, 2009. The last activity note in record review #1 was entered on July 31, 2009.
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Plan of Correction
The Project Director, Facility Coordinator, facility Managers, facility Assistant Managers will document any/all activities, problems, concerns or other information relative to each client in the clients' respective file.
The Facility Coordinator will review all files on a monthly basis to monitor case file notations. Each note will be initialed by the Facility Coordinator. |