INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from June 27-28, 2013, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, James A. Casey House, 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that the building and grounds were kept clean, safe, sanitary and in good repair at all times.The findings include:The physical plant inspection was conducted on June 28, 2013, from approximately 8:35 AM to 10:00 AM. The following safety, sanitation, cleanliness and/or repair issues were observed:The lower window pane in bedroom # 9-2 and the upper window pane in bedroom # 5-3 were broken and had sharp edges exposed.There were three bags of trash on the floor of bedroom # 1-3. In addition, empty plastic bottles and paper debris were on the floor of the bedroom.The closet in apartment # 4 that contained the hot water heater also had an iron, a cardboard box, electrical cords, an unknown electrical component and clothes which were found on the floor of the closet. The facility utilized a fire escape in the rear of the building as a means of exiting from the building. The 2nd step from the bottom of the fire escape leading from the 3rd to the 2nd floor was not secured to the fire escape. In addition, the first step of the fire escape leading from the 2nd to 1st floor was not secured to the fire escape.The findings were confirmed by the building owner during the physical plant inspection.
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Plan of Correction
The cracked window panes in 9-2 and 5-3 have been replaced. The garbage in 1-3 has been removed. The water heater closet in Apt #4 has been cleaned of all debris. And all loose steps on the fire escape have been secured.
Weekly inspections by the Building Maintenance Manager as well as feedback from clients and staff will ensure that the building and grounds are kept clean, safe, sanitary and in good repair at all times.
The Building Maintenance Manager is responsible for keeping the building and grounds clean, safe, sanitary and in good repair.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the results of the physical plant inspection, the facility failed to ensure that the hot water temperature in four of five apartment bathrooms on the second floor and in one of one apartment bathrooms on the first floor did not exceed 120F. The findings include:The physical plant inspection was conducted on June 28, 2013, from approximately 8:35 AM to 10:00 AM. The water temperature exceeded 120F in the bathrooms of apartments # 1, 3, 4, 5 and 7. The following water temperatures were recorded in the respective bathrooms:Bathroom # 1 - 128FBathroom # 3 - 133FBathroom # 4 - 136FBathroom # 5 - 125FBathroom # 7 - 127FThe building owner confirmed the findings during the physical plant inspection.
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Plan of Correction
The hot water heaters have been turned down and the temperature of the water is now below 120 degrees in all of the apartments. The facility has purchased a new thermometer to better measure the water temperatures as well. Through weekly inspections of the apartments the Project Administrator and Building Maintenance Manager will ensure that the water temperatures in the apartments do not exceed 120 degrees. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on the results of the physical plant inspection, the facility failed to equip a designated bedroom within the residential treatment facility with a detection device so that each person with a hearing impairment will be alerted in the event of a fire.The findings include:The physical plant inspection was conducted on June 28, 2013, from approximately 8:35 AM to 10:00 AM. The residential treatment program provides housing for its clients on the third floor of the facility. The facility failed to equip a bedroom on the third floor with a detection device so that the hearing impaired would be alerted in the event of a fire.The building owner confirmed the findings during the physical plant inspection.
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Plan of Correction
Bedroom 11-3 has now been equipped with a detection device so that the hearing impaired will be alerted in the event of a fire. The Building Maintenance Manager will ensure that the facility meets all fire safety standards. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based upon the review of employee records, the facility failed to document an annual performance evaluation in one of one employee records.The findings include:One employee record requiring documentation of an annual evaluation was reviewed on June 28, 2013. The facility failed to document an annual evaluation for employee # 2 for the time frame of January 1, 2012 to December 31, 2012.Employee # 2 was the Project Director from October 1, 2010 to May 31, 2013. As of the date of inspection, The personnel record for employee # 2 did not include an annual evaluation for the time frame of January 1, 2012 to December 31, 2012.The findings were confirmed by the Project Coordinator during the employee record review.
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Plan of Correction
All employees will receive an annual personnel evaluation on the yearly anniversary of their employment with the James A. Casey House. The evaluations will be completed by the immediate supervisor or a staff member designated by the governing body.
The Project Administrator will conduct semi-annual inspections of the employee records and will ensure that personnel evaluations are completed on all staff by notifying the supervisor of any ourstanding or upcoming evaluations.
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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 upon the review of client records, the facility failed to obtain an informed and voluntary consent for the release of information from two of eight client records.The findings include:Eight client records were reviewed on June 27, 2013. The facility failed to obtain informed and voluntary consent for the release of information from client records # 6 and 7. Client # 6 was admitted on February 22, 2013, and was still an active client on the date of inspection. The client record included documentation of a release of information that was dated May 29, 2013. However, as of the date of inspection, the record did not include a signed consent form from the client for the party to whom the disclosure was made.Client # 7 was admitted on October 25, 2012, and was still an active client on the date of inspection. The record included documentation of a release of information regarding the client's rent for April, May and June. However, as of the date of inspection, the record did not include a signed consent form from the client for the party to whom the disclosure was made.The findings were confirmed by the Project Coordinator during the exit interview.
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Plan of Correction
Whenever the James A. Casey House staff release information about a client in the future they will obtain an informed and voluntary consent for the release of that information. The Project Administrator will be responsible for ensuring that no information about a client is released without their consent by inspecting the client record during the monthly progress evaluation. |
709.71(b)(1) LICENSURE Disclosure to client
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, completion and discharge.
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Observations
Based upon the review of client records, a review of the facility's policy and procedure manual and an interview with the Project Coordinator, the facility failed to follow its policy in regard to documenting the disclosure to the client of the criteria for admission, completion and discharge in three of eight client records. The findings include:The facility's policy and procedure manual included the following documentation in regard to the criteria for admission, completion and discharge:"Subpart 709.71: Intake and Admission709.71(a)(1): Upon admission interview, potential clients are advised of admission criteria and must sign an Admission Criteria form which is included in their personal records at Crossing Over.709.71(a)(2): The completion of treatment will be determined......Clients will be advised of this plan and will sign a Completion of Residency form at initial admission interview.709.71(a)(3): Clients will be involuntarily discharged......Clients will be advised of this and will sign a form at initial admission interview acknowledging his understanding."The Project Coordinator was interviewed on June 27, 2013, and clarified that several documents that are a part of the the intake and admission process (initial admission interview) are to be reviewed with and signed by the client on the first day of admission. He also stated that the remaining documents, which included the criteria for admission, completion and discharge, are to be reviewed with and signed by the client by the end of the first week after admission.Eight client records requiring documentation of the disclosure to the client of criteria for admission, completion and discharge were reviewed on June 27, 2013. The facility failed to follow its policy in regard to documenting the disclosure in client records # 3, 4 and 7.Client # 3 was admitted on November 30, 2012. As per facility policy, the disclosure to the client of the criteria for admission, completion and discharge was to be reviewed and signed by the client no later than December 7, 2012. However, as per documentation contained in the client record, the disclosure was not signed by the client until January 18, 2013.Client # 4 was admitted on December 11, 2012. As per facility policy, the disclosure to the client of the criteria for admission, completion and discharge was to be reviewed and signed by the client no later than December 18, 2012. However, as per documentation contained in the client record, the disclosure was not signed by the client until January 22, 2013.Client # 7 was admitted on October 15, 2012. As per facility policy, the disclosure to the client of the criteria for admission, completion and discharge was to be reviewed and signed by the client no later than October 22, 2012. However, as per documentation contained in the client record, the disclosure was not signed by the client until December 10, 2012.The Project Coordinator reconfirmed the findings during the exit interview.
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Plan of Correction
All clients will be required to complete all intake documents, including the disclosure to the client of the criteria for admission, completion and discharge, within 5 days of intake.
The Project Administrator will be responsible for ensuring that all paperwork is completed in the appropriate timeframe by reviewing them client records at the mothly progress evaluation.
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709.71(b)(2)(i) LICENSURE Orientation/house rules
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:
(i) House Rules
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Observations
Based upon an interview with the Project Coordinator and the review of client records, the facility failed to document client orientation to the project as part of the intake process in three of eight client records. The findings include:The Project Coordinator was interviewed on June 27, 2013, and stated that client orientation to the project is to be conducted within a week of admission as part of the intake process. The Project Coordinator confirmed that client orientation is verified via a sign-off form that is maintained in the client record.Eight client records requiring documentation of client orientation to the project were reviewed on June 27, 2013. The facility failed to document that client orientation was conducted as part of the intake process in client records # 3, 4 and 7.Client # 3 was admitted on November 30, 2012, and client orientation to the project was to be conducted no later than December 7, 2012. However, as per documentation contained in the client record, client orientation to the project was not conducted until January 18, 2013.Client # 4 was admitted on December 11, 2012, and client orientation to the project was to be conducted no later than December 18, 2012. However, as per documentation contained in the client record, client orientation to the project was not conducted until January 22, 2013.Client # 7 was admitted on October 15, 2012, and client orientation to the project was to be conducted no later than October 22, 2012. However, as per documentation contained in the client record, client orientation to the project was not conducted until December 10, 2012.The Project Coordinator reconfirmed the findings during the exit interview.
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Plan of Correction
Client orientation to the project will be completed with the other intake documents and will be completed no later than 5 days after intake.
The Project Administrator will be responsible for ensuring that all paperwork is completed in the appropriate timeframe by reviewing the client records at the mothly progress evaluation.
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