INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 24, 2009 licensure renewal inspection. The follow-up inspection was conducted on September 30, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 October 28, 2009.
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Plan of Correction
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709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on a review of personnel records, facility training documents and an interview with the Project Coordinator, who reports to the Project Director, the facility failed to compose and execute job descriptions for positions at this facility.
The findings include:
There were no signed and dated job descriptions at the facility as of September 30, 2009, the date of the plan of correction follow up inspection. Job descriptions were defined in the facility manual, but were never composed as a document that could be signed and dated by the employee and the supervisor. The approved plan of correction indicated that this would be in compliance as of May 12, 2009. Job Descriptions were missing for the following employees:
Employee # 1 - Project Director - There was no personnel file and no documentation of the job description.
Employee # 2 - Project Coordinator - There was no documentation of a job description in the personnel record.
Employee # 3 - Manager - There was no documentation of a job description in the personnel record.
Employee # 4 - Manager - There was no documentation of a job description in the personnel record.
Employee # 5 - Assistant Manager - There was no documentation of a job description in the personnel record.
Employee # 6 - Assistant Manager - There was no documentation of a job description in the personnel record.
Employee # 7 - Manager - There was no documentation of a job description in the personnel record.
Employee # 8 - Assistant Manager - There was no documentation of a job description in the personnel record.
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Plan of Correction
The personnel files for the Project Director, the Project Coordinator and for each Manager position and the Assistant Manager position, maintained at Crossing Over, will contain a signed Job Description. The Project Director and the Project Coordinator will review each personnel file semi-annually to assure each file is maintained as required by the licensure standards. The corrections will be completed immediately. |
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
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Observations
Based on a review of personnel records, facility training documents and an interview with the Project Coordinator, who reports to the Project Director, the facility failed to compose and execute job descriptions for positions at this facility.
The findings include:
There were no signed and dated job descriptions at the facility as of September 30, 2009, the date of the plan of correction follow up inspection. Job descriptions were defined in the facility manual, but were never composed as a document that could be signed and dated by the employee and the supervisor. The approved plan of correction indicated that this would be in compliance as of May 12, 2009. Job Descriptions were missing for the following employees, and thus a description of the requisite skills, knowledge and experience was missing from the following personnel records:
Employee # 1 - Project Director - There was no personnel file and no documentation of the job description, or the requisite skills, knowledge and experience .
Employee # 2 - Project Coordinator - There was no documentation of a job description in the personnel record or the requisite skills, knowledge and experience.
Employee # 3 - Manager - There was no documentation of a job description in the personnel record or the requisite skills, knowledge and experience.
Employee # 4 - Manager - There was no documentation of a job description in the personnel record or the requisite skills, knowledge and experience.
Employee # 5 - Assistant Manager - There was no documentation of a job description in the personnel record or the requisite skills, knowledge and experience.
Employee # 6 - Assistant Manager - There was no documentation of a job description in the personnel record or the requisite skills, knowledge and experience.
Employee # 7 - Manager - There was no documentation of a job description in the personnel record or the requisite skills, knowledge and experience.
Employee # 8 - Assistant Manager - There was no documentation of a job description in the personnel record or the requisite skills, knowledge and experience.
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Plan of Correction
The personnel files of the Project Director, the Project Coordinator and for each of the Manager nad Assistant Manager positions (presently and in the future) will contain a signed job description that specifically describes all the requisite skills, knowledge and experience for those positions. The Project Director and/or the Project Coordinator will review and/or update those files semi-annually and will revise the job descriptions as necessary. These personnel files will have the required changes (corrections) made immediately. |
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 and interviews with the Project Coordinator and the Assistant Manager, the facility failed to ensure that the written consents to release information were completed in five of five client records reviewed.
The findings include:
Five client records were reviewed on September 30, 2009 from 11:00 A.M. to 12:20 P.M. The Project Coordinator and an Assistant Manager were interviewed from 12:20 P.M. to 12:30 P.M. regarding the status of the five clients and the condition of their records of residency. The Project Coordinator confirmed that written consent to release information forms were not consistently obtained and/or completed in the following client records:
Client #1 - Admitted 9/8/08 - A consent to release information form was signed and dated, but was not complete, in that there was no indication of who was to receive the client identifying information and what the purpose was for the release of information.
Client # 2 - Admitted 8/21/09 - A consent to release information form was signed and dated, but was not complete, in that there was no indication of who was to receive the client identifying information and what the purpose was for the release of information.
Client # 3 - Admitted 7/6/09 - A consent to release information form was signed and dated, but was not complete, in that there was no indication of who was to receive the client identifying information and what the purpose was for the release of information.
Client # 4 - Admitted 9/12/09 - The client and witness signed and dated a blank consent to release information form. There was no indication of who was to receive the information; what information was going to be released; what the purpose was for the release of information; and what the expiration date of the consent would be.
Client # 5 - Admitted 9/23/09 - A consent to release information form was signed and dated, but was not complete, in that there was no indication of who was to receive the client identifying information.
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Plan of Correction
The Project Director and/or the Project Coordinator will review all client records to confirm that all Consent for Release forms are properly completed with information specific to the client. The information will include: name of client, who is requesting or who is to receive the information, the name of the staff member releasing the information, the reasons for the relaese of information and the type of information to be released as lilited by all laws regarding client confidentiality. The deficient client files will be corrected immediately and additional training will be given to new staff regarding Consent for Release standards for all future clients. |