INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2011 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.
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Plan of Correction
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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 the review of employee training records during the onsite inspection of 8/9/11 , the facility failed to document an individual training plan on each newly hired employee within one month of the date of hire.
The findings included:
During the onsite inspection of 8/9/2011 the training records of six employees were reviewed. Two of these employees were hired on 6/20/2011. At the time of the inspection no individual training plans were documented for either of these employees.
The findings were reviewed with the owner and project coordinator and were not disputed.
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Plan of Correction
Individual training plans have been developed for each of the new employees and placed in their employee training folders. All employees will receive updated individual training plans for 2012 in November, 2011. The Project coordinator will be responsible for ensuring that all new employees receive individual training plans within the first month of being hired. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of the agency fire drill log documentation and a discussion with the project coordinator, the facility failed to document fire drills each month since the last regular licensing inspection completed on 4/6/2011.
The findings included:
The fire drill records were reviewed during the inspection held on 8/9/2011. Fire drills were conducted each month from April 2011 through June 2011. No fire drill was documented for the month of July 2011.
During an interview with the project coordinator he acknowledged that this was an oversight and that staff failed to conduct a July fire drill.
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Plan of Correction
A fire drill was conducted on 8/23/11 and was documented in the facility's fire drill log. The Project Coordinator will be responsible for ensuring that the facility conducts a fire drill each month. |
709.26(a)(2) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(2) Utilization of volunteers.
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Observations
Based on the review of personnel files and the approved plan of correction submitted for the licensing inspection conducted on 4/6/2011, the facility failed to ensure that reference checks were obtained on each employee as required.
The findings included:
The onsite inspection as conducted on 8/9/2011. During the inspection six personnel records were reviewed. The plan of correction submitted and approved on 5/6/2011 stated that "reference checks will be done to make sure these requirements are met." Six employee records were reviewed, five were missing reference checks. Two of these employees were new hires since the last inspection.
Employees # 5 and 6 were hired 6/20/11. Neither of the employees had documentation of reference checks in their records.
Employees of longer standing were also missing reference checks.
Employee # 1 - hired on 10/1/10 had no documentation of a reference check at the time of the inspection on 8/9/11.
Employee # 2 - hired on 6/3/08 had no documentation of a reference check at the time of the inspection on 8/9/11.
Employee # 3 - hired on 1/11/05 had no documentation of a reference check at the time of the inspection on 8/9/11.
Employee # 4 - hired on 6/1/10 had no documentation of a reference check at the time of the inspection on 8/9/11.
The findings were reviewed with the Project Coordinator and Owner and were not disputed.
This is a repeat citation .
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Plan of Correction
All employees will have personal reference checks placed in their folders within thirty days. The Project Coordinator will be responsible for ensuring that all staff have educational and professional references as well as personal character references when hired. |
709.26(d)(5)(ii) 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:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Based on the review of personnel records and an interview with the Project Coordinator during the onsite licensing inspection of 8/9/2011, the facility failed to document annual performance evaluations in accordance with written facility procedure.
The findings included:
During the onsite licensing inspection of 8/9/2011, six staff records were reviewed. Three of four applicable records failed to include documentation of annual and probationary performance as required by regulation and agency procedure.
Employee # 1 was hired on 10/1/10. There was no documentation of a probationary evaluation at 6 months as required by written facility policy and procedure.
Employee # 2 was hired on 6/23/08 . The last documented performance evaluation was documented on 7/1/10.
Employee # 3 was hired on 1/11/05. The last documented performance evaluation was documented on 7/1/10.
Employee # 4 was hired on 6/1/10. The last documented performance evaluation was documented on 7/1/10.
The Project Coordinator was interviewed at approximately 11 AM and acknowledged that the performance evaluations were not completed in several of the records as required.
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Plan of Correction
Performance evaluations have been conducted with employees #1, #2, #3. and #4. The Project Coordinator will be responsible for ensuring that all staff complete a performance evaluation annually. |