INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on June 20, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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:
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Plan of Correction
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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 the review of employee records and an interview with the Project Coordinator, the facility failed to ensure that sufficient staff maintained current certification in CPR to cover all hours of operation.
The findings include:
All facility personnel records were reviewed and an interview was conducted with the Project Coordinator during the licensure renewal inspection conducted on June 20, 2012. No documentation of current CPR certification was located in employee records and the Project Coordinator verified that CPR certification had expired for all employees on May 21, 2012. Attempts to have a CPR trainer provide the re-certification class for staff have been unsuccessful to date due to the trainer having to cancel for personal reasons. The Project Coordinator related that the CPR re-certification class is scheduled for June 23, 2012.
The findings were reviewed with the Project Coordinator and governing body ( owner) and were not disputed.
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Plan of Correction
CPR/AED training was completed for all employees on 6/22/12. The Project Coordinator will be responsible for ensuring that all employees are certified in CPR/AED. |
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 the review of the fire drill log, the facility failed to ensure that alternate exits were used during fire drills .
The finding includes:
The facility fire drill log was reviewed during the licensure renewal inspection conducted on June 20, 2012. No documentation was included in the fire drill log to verify that alternate exits were used during fire drills. The Project Coordinator confirmed that the front door was always used to exit the building for the fire drills.
The finding was reviewed with the Project Coordinator and governing body (owner) and was not disputed.
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Plan of Correction
An alternate exit will be used for the next facility fire drill due to take place in July. This will be recorded in the facility fire drill log. The Project Coordinator will be responsible for ensuring that fire drills are conducted appropriately. |
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 the review of the facility policy manual, the facility failed to ensure that the Project director completed an annual review and update of the manual.
The finding includes:
The facility policy manual was reviewed during the licensure renewal inspection conducted on June 20, 2012. No documentation was included in the manual to verify that the Project Director had completed the annual review and update of the manual. The last sign off on the manual by the Project Director was dated 4/1/11.
The finding was reviewed with the Project Coordinator and governing body (owner) and was not disputed.
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Plan of Correction
The Project Director and Owner completed an annual review and update of the manual on 7/2/12. This will be done again in January. The Project Coordinator will be responsible for ensuring that the Project Director and Owner review and update the manual each year in January. |
709.23(b) 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:
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Observations
Based on the review of the facility policy manual, the facility failed to document that the Project Director and the governing body collaborated on the formulation of project goals and objectives.
The finding includes:
The facility policy manual was reviewed during the licensure renewal inspection conducted on June 20, 2012. No documentation was included in the manual to verify that the Project Director and the governing body collaborated on the formulation of project goals and objectives for the year.
The finding was reviewed with the Project Coordinator and governing body (owner) and was not disputed.
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Plan of Correction
The Project Director and Owner have signed off on the facilities goals and objectives for 2012. The Project Coordinator will be responsible for ensuring that the Project Director and Owner collaborate on the formulation of project goals and objectives each year. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on the physical plant inspection, the facility failed to remain within its licensed capacity by exceeding the maximum number of beds approved by the Division.
The finding includes:
A physical plant inspection was conducted and a bed count was completed during the licensure renewal inspection on June 20, 2012. The facility had 39 beds available at the time of the inspection . The licensed capacity for the facility as approved by the Division was 35 beds.
The finding was reviewed with the Project Coordinator and was not disputed.
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Plan of Correction
We have submitted the appropriate documentation to the Division and are waiting to hear their decision on increasing our approved number of beds. If the increase is not granted we will disassemble the remaining beds. The Project Coordinator will be responsible for ensuring that the facility does not exceed its approved number of beds. |