INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 7, 2015 by staff from the 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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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
The facility failed to meet the pre-submission guidelines for the annual licensing inspection. The time allotted for the onsite portion of the inspection did not allow for the review of that material on site.
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Plan of Correction
The attestations were corrected on 12/7/15 by the Project Director C. Ross Livingstone. In the future the Project Director will be responsible for ensuring that attestations are properly filled out by double checking all forms submitted to DDAP. |
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
The facility failed to meet the pre-submission guidelines for the annual licensing inspection. The time allotted for the onsite portion of the inspection did not allow for the review of that material on site.
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Plan of Correction
The attestations were corrected on 12/7/15 by the Project Director C. Ross Livingstone. In the future the Project Director will be responsible for ensuring that attestations are properly filled out by double checking all forms submitted to DDAP. |
709.23(b)(2) 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:
(2) Written reports of project operations.
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Observations
The facility failed to meet the pre-submission guidelines for the annual licensing inspection. The time allotted for the onsite portion of the inspection did not allow for the review of that material on site.
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Plan of Correction
The attestations were corrected on 12/7/15 by the Project Director C. Ross Livingstone. In the future the Project Director will be responsible for ensuring that attestations are properly filled out by double checking all forms submitted to DDAP. |
709.26(a) 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:
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Observations
The facility failed to meet the pre-submission guidelines for the annual licensing inspection. The time allotted for the onsite portion of the inspection did not allow for the review of that material on site.
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Plan of Correction
The attestations were corrected on 12/7/15 by the Project Director C. Ross Livingstone. In the future the Project Director will be responsible for ensuring that attestations are properly filled out by double checking all forms submitted to DDAP. |
709.26(b)(1) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(1) Confidential maintenance of personnel records.
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Observations
The facility failed to meet the pre-submission guidelines for the annual licensing inspection. The time allotted for the onsite portion of the inspection did not allow for the review of that material on site.
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Plan of Correction
The attestations were corrected on 12/7/15 by the Project Director C. Ross Livingstone. In the future the Project Director will be responsible for ensuring that attestations are properly filled out by double checking all forms submitted to DDAP. |
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 a physical plant inspection, the facility failed to ensure that all mattresses were in good condition.
The findings include:
The physical plant inspection took place on December 7, 2015 at around 2:00 pm. During the physical plant inspection the mattresses were randomly spot checked for cleanliness and good repair. In room 4 of Apt 2, the mattress and mattress cover was taped together with black wire tape.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The mattress cover was removed from the bed on 12/7/15. In the future the Building Maintenance Director will be responsible for ensuring that all mattresses are in good condition by inspecting all rooms every time they are vacated. |
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 a review of the physical plant inspection, the facility failed to ensure that the water temperature did not exceed 120 degrees.
The findings include:
During the physical plant inspection on December 7, 2015, at 10:50 AM., the hot water temperature in the men's bathroom next to the administrator's office exceeded the required 120 degrees. The hot water temperature was recorded at 140.0 degrees Fahrenheit.
Additionally, in apartment #11 bathroom, the hot water knob was striped and would not remain screwed on, would not grip in order for hot water to be turned on in the sink. This Licensing Specialist couldn't determine the hot water's pressure due to the striped knob.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hot water for the men's bathroom next to the administrator's office was turned down on 12/7/15. Additionally the hot water knob in Apt #11 was fixed on 12/7/15. The Building Maintenance Director will be responsible for ensuring hot water is available at the appropriate temperature by conducting monthly inspections. |
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 a review of personnel and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in three of four records reviewed
The findings include:
Four personnel records which required documentation of mandatory communicable disease training were reviewed on December 7, 2015. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employees #5, #6 and #8.
Employee #5 was hired 06/19/2013, as a counselor. This employee was required to obtain 6 hours of HIV/AIDS and 4 hours of TB/STD training by 06/19/2014. Employee #5 failed to obtain the 4 hours training in TB/STDs as of the date of the onsite inspection.
Employee #6 was hired 07/21/2014, as a counselor. This employee was required to obtain 6 hours of HIV/AIDS and 4 hours of TB/STD training by 07/21/2015. Employee #6 failed to obtain the 6 hours training in HIV/AIDS and the 4 hours training in TB/STDs as of the date of the onsite inspection.
Employee #8 was hired 06/01/2013, as the project director. This employee was required to obtain 6 hours of HIV/AIDS and 4 hours of TB/STD training by 06/01/2015. Employee #8 failed to obtain the 4 hours training in TB/STDs as of the date of the onsite inspection
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Plan of Correction
All personnel will receive the mandatory training for HIV/AIDS and TB/STD within the first six months of the program year (2016). The Project Director will be responsible for ensuring that all staff have the appropriate training during their annual personnel review. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of the required 12 hours of annual training for the Project Director in one of one personnel records reviewed.
The findings include:
One personnel record for the project director requiring the documentation of the completion of 12 clock hours of annual training was reviewed on December 10, 2015. The facility failed to document the completion of 12 clock hours of annual training for employee #8.
Employee # 8 was hired on 06/01/2013, as the project director. The facility training year is from January to December. The training year for January 1, 2014, to December 31, 2014, was reviewed. Employee # 8 completed 0 clock hours of annual training for the January 1, 2014, to December 31, 2014, training year.
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Plan of Correction
Employee #8 will complete 12 hours of training during the first six months of the program year (2016) The Project Director will be responsible for ensuring that all staff have the appropriate training during their annual personnel review.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 training hours required for counselors in one of two personnel records reviewed.
The findings include:
Two personnel records of counselors requiring the documentation of the completion of 25 clock hours of annual training were reviewed on December 10, 2015. The facility failed to document the completion of 25 clock hours of annual training for employee #5.
Employee # 5 was hired on 06/19/2013, as a counselor. The facility training year is from January to December. The training year for January 1, 2014, to December 31, 2014, was reviewed. Employee # 5 only completed 15 clock hours of annual training for the January 1, 2014, to December 31, 2014, training year.
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Plan of Correction
All staff will attend and complete the required number of training hours during the program year (2016). The Project Director will be responsible for ensuring that all staff have the appropriate training during their annual personnel review. |