INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 3, 2010 licensure renewal inspection. The follow-up inspection was conducted on October 27, 2010 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 November 29, 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 interviews 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.
Facility staff failed to appear to grant access to required material during the October 27, 2010 plan of correction follow up inspection.
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Plan of Correction
An annual facility staff development plan, including name/type training; proposed trainer and proposed date of training has been established by the Facility Director and includes 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.
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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 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.
Facility staff failed to appear to grant access to required material during the October 27, 2010 plan of correction follow up inspection.
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Plan of Correction
In October of each 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.
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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.
Employee # 3 was 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.
Employee # 5 was 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.
Facility staff failed to appear to grant access to required material during the October 27, 2010 plan of correction follow up inspection.
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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. The training was provided on May 18, 2009 by Certified Instructor Sharon Whitebread of the American Red Cross. Project Director will be responsible fo making sure that all staff members are properly trianed. |
705.1 (3) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
Based on a physical plant inspection conducted during the unannounced plan of correction follow up, the facility failed to ensure that the physical plant was maintained in a safe manner and in accordance with federal, state and local ordinances.
The findings included:
During the physical plant inspection on 10/27/10 between 10:30 A.M. and 11:30 A.M. Division staff observed wires to the smoke detection system running along the ceiling. The wires were not run in conduit, the wire connections were not located in junction boxes. This problem was observed in the first floor storage area. Several areas of the building could not be accessed during the inspection because the staff person on duty did not have keys to all the apartments during the inspection . All areas of concern were pointed out to the house manager on duty and he acknowledged the issues pointed out were valid.
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Plan of Correction
All smoke detector wires are maintained in a safe manner and in accordance with federal, state and local ordinances. Smoke detectors act as their own junction box and the low volt wires do not need conduits.
All wires and connections will be concealed in the appropriate conduit or junction box, and will not be hanging from the ceiling. The Facility Maintenance Director will be responsible for maintaining all aspects of the physical plant. |
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 on the physical plant inspection conducted during the unannounced plan of correction follow up, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times.
The findings included:
The rear exit onto the second floor fire escape had a makeshift handle attached to the outside surface of the door which was made of sharp edged, rusted sheet metal, The rear door onto the third floor fire escape had the veneer torn completely off the door. Trash was seen on the second and third floor fire escape landings and stairs at the time of the inspection.
The interior of the facility had soiled and badly worn carpets in the intake office area, in client apartments # 6 and # 11, and in the laundry area. The laundry area was dirty, lint was hanging on the walls in several spots. Lint was noted behind the dryers. Many of the ceiling tile throughout the facility were broken, cracked or stained. Cobwebs were noted along the ceilings in several areas of the corridors. The physical plant inspection occurred 10/27/10 between 10:30 A.M. and 11:30 A.M. . The issues identified by Division staff were pointed out to the house manager on duty and he concurred that the observations were valid concerns.
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Plan of Correction
The handle to the second floor fire escape has been removed. The rear fire escape has been cleaned of trash. The laundry area has also been cleaned. Although the carpets may appear to be soiled and worn they have been vigorously cleaned and sanitized and are more than adequate for our use. If any additional cleaning is required it will be performed as soon as possible. The Facility Maintenance Director will be responsible for maintaining all aspects of the physical plant. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on the physical plant inspection conducted during the unannounced plan of correction follow up, the facility failed to maintain beds which were in good repair and mattresses which were fire retardant.
The findings included:
Division staff conducted an inspection of the client apartments and spot checked some of the mattresses on the beds. The box springs in Room # 3 had a burn spot where a client had apparently burned a hole in the mattress to hide a cigarette lighter. The mattress was soiled and in poor condition at the time of the inspection. Mattresses were spot checked in apartments 6 and 11 and were observed to be soiled . No documentation of fire retardant status was found on mattresses. The staff person on duty did not have access to the office where additional documentation was kept so no documentation of fire retardant status could be verified during the inspection. The physical plant inspection occurred 10/27/10 between 10:30 A.M. and 11:30 A.M. .
The issues identified by Division staff were pointed out to the house manager on duty and he concurred that the conditions were as stated.
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Plan of Correction
All mattresses are fire retardant and while they may appear to be soiled they have been vigorously cleaned and sanitized. All mattresses that were in poor condition have been replaced. The Facility Maintenance Director will be responsible for maintaining all aspects of the physical plant. |
705.5 (j) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(j) A residential facility shall prohibit smoking and use of candles in bedrooms.
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Observations
Based on the physical plant inspection conducted during the unannounced plan of correction follow up, the facility failed to insure that clients do not smoke in bedrooms.
The findings included:
During the physical plant inspection a client was observed smoking in a bedroom in Apartment 6. The physical plant inspection occurred 10/27/10 between 10:30 A.M. and 11:30 A.M. . The issues identified by Division staff were pointed out to the house manager on duty and he concurred that the observations were valid concerns.
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Plan of Correction
There are signs in each apartment stating that smoking in bedrooms is prohibited. The individual caught smoking has been reprimanded and the house manager on duty will be responsible to making sure that no one smokes in their bedrooms. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on the physical plant inspection conducted during the unannounced plan of correction follow up, the facility failed to maintain ventilation in each bathroom .
The findings included:
Bathrooms were inspected by Division staff during the physical plant inspection. Exhaust fans were not working in bathrooms in Apartments 6 and 11. The physical plant inspection occurred 10/27/10 between 10:30 A.M. and 11:30 A.M. .
The issues identified by Division staff were pointed out to the house manager on duty and he concurred that the issues were stated as observed.
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Plan of Correction
The bathrooms in Apartments #6 and #11 each have windows that can be opened to ventilate the bathroom. There was a curtain in front of one window, but behind the curtain was a functioning window. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on the physical plant inspection during the unannounced licensing inspection, the facility failed to maintain each bathroom in a clean and sanitary manner at all times.
The findings included:
Division staff asked to inspect the facility during the unannounced inspection. Not all rooms were accessible to Division staff because some clients were at work and the staff on duty did not have a key to allow access to some of the rooms. The bathrooms in the apartments inspected were not kept clean.
The bathroom in apartment 6 had moldy caulking that was not effectively sealing the cracks in the shower stall. The tub in apartment six was dirty with soap scum and rust stains apparent on the sides of the tub.
The tub and sink in apartment 11 was not clean at the time of the inspection as evidenced by a soap scum film on the surface of each.
The physical plant inspection occurred on 10/27/10 between 10:30 A.M. and 11:30 A.M. . The issues identified by Division staff were pointed out to the house manager on duty and he concurred that the were stated as observed.
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Plan of Correction
As part of Transitional Living our clients are required to clean their own bathrooms with the daily oversight of management. The bathrooms in question will be cleaned regularly with daily oversight from management. The Project Director will be ultimately responsible for ensuring that cleanliness is maintained. |
705.7 (b) (2) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on the physical plant inspection during the unannounced licensing inspection, the facility failed to clean and disinfect food preparation areas after each meal.
The findings included:
Division staff conducted a physical plant inspection while onsite. The food preparation areas were not cleaned and disinfected after each meal. Dirty dishes were stacked in the sinks in apartments 6 and 11. Odors were noted in each of the kitchen areas. The veneer on one of the kitchen cabinets in apartment 11 was stripped off leaving a porous wooden service for bacteria to grow. The physical plant inspection occurred 10/27/10 between 10:30 A.M. and 11:30 A.M.
The issues identified by Division staff were pointed out to the house manager on duty and he concurred that the issues were stated as observations.
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Plan of Correction
We do not have a "central food preparation area" as described in 705.7. (b). Each apartment has its own kitchen and as part of Transitional Living our clients are required to clean their own kitchen with the oversight of the management. The kitchens in question will be cleaned regularly with the oversight of management. The kitchen in Apartment #11 is currently under construction for a new stove and cabinets and will be finished sometime in the next month. The Facility Maintenance Director will be responsible for maintaining all aspects of the physical plant. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection during the unannounced action plan follow up, the facility failed to prohibit the use of portable space heaters.
The findings included:
Division staff observed a portable space heater located in the intake room adjacent to the house manager's office. The physical plant inspection occurred 10/27/10 between 10:30 A.M. and 11:30 A.M. . The issues identified by Division staff were pointed out to the house manager on duty and he concurred that the issue was stated as observed.
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Plan of Correction
The space heater in question was broken. It had been dropped off here and was being thrown out. We do not allow space heaters in the building. It has been removed and no more will be allowed on the premises. The Facility Maintenance Director will be responsible for maintaining all aspects of the physical plant. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on the results of a physical plant inspection and an interview with facility staff, smoking in the facility is not limited to the designated areas. The house manager acknowledged that smoking is not to occur in apartments but that given the nature of the population served, enforcement of this requirement is difficult.
The findings included:
During the physical plant inspection, one client was observed smoking in his bedroom in room # 6. Other evidence of smoking in the facility included a cigarette lighter found in a box spring in room # 3, yellowed ceiling tiles from nicotine staining and stale cigarette odors in apartments 6 and 11. The physical plant inspection occurred 10/27/10 between 10:30 A.M. and 11:30 A.M. The issues identified by Division staff were pointed out to the house manager on duty and he concurred that the issues were stated as observed.
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Plan of Correction
Clients are allowed to smoke in all areas of the facility except for their bedrooms as mandated by 705.5. (j) and in the management office as most members of management do not smoke. The house manager on duty will be responsible for making sure that smoking only occurs in designated areas. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on the results of a physical plant inspection conducted during the unannounced inspection, the facility failed to insure that an exit sign was posted over each designated fire exit.
The findings included:
Division staff observed that designated fire exits on the first floor rear exit and the third floor hallway exit did not have exit signs posted as required. The physical plant inspection occurred 10/27/10 between 10:30 A.M. and 11:30 A.M. The issues identified by Division staff were pointed out to the house manager on duty and he concurred that the issues were stated as observed.
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Plan of Correction
Fire exits on the first floor rear exit and the third floor hallway exit have been properly posted with signs. The Facility Maintenance Director will be responsible for maintaining all aspects of the physical plant. |
705.10 (b) (1) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(1) Maintain a minimum of one operable, automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on the physical plant inspection, the facility failed to ensure that a smoke detector was located on each floor including the attic and the basement as required.
The findings included:
Division staff inspected the physical plant while onsite. The attic was inaccessible during the inspection so no determination could be made about the presence of a smoke detector. The basement was inspected and was observed to be poorly lighted at the time of the inspection . Division staff and the house manager on duty searched the basement for a smoke detector but were unable to locate one. The physical plant inspection occurred on 10/27/10 between 10:30 A.M. and 11:30 A.M.
The issues identified by Division staff were pointed out to the house manager on duty and he concurred that the issues were stated as observed.
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Plan of Correction
The facility does not have an attic, the staircase that was inaccessible leads directly to the roof and therefore no smoke detector is needed. There is a smoke detector in the basement along with a strobe light smoke detector. The basement is also well lit if all the lights are turned on. |
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, a review of the 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.
Facility staff failed to appear to grant access to required material during the October 27, 2010 plan of correction follow up inspection.
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Plan of Correction
A fire drill during sleeping hours was completed on June 16, 2010 at 12:00AM.
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.
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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 severe losses for the last two fiscal years. They confirmed on June 3, 2010 that audits were not completed for this LLC company
Facility staff failed to appear to grant access to required material during the October 27, 2010 plan of correction follow up inspection.
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Plan of Correction
Due to a complete lack of any fiscal activity for Crossing Over Apartments LLC we will provide a copy of the tax returns, performed by an independent public accountant, for Crossing Over Apartments LLC instead of an audit. We'll have a audit from a reputable CPA by the end of January. Jim Casey will be resposible for all fiscal acivities. |
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.
Facility staff failed to appear to grant access to required material during the October 27, 2010 plan of correction follow up inspection.
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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, 2010. 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.
Facility staff failed to appear to grant access to required material during the October 27, 2010 plan of correction follow up inspection.
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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.
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