INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted April 28, 2022, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Kirkbride Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.3(d) LICENSURE 24 Hour Coverage
704.3. General requirements for projects.
(d) Inpatient nonhospital facilities except for transitional living facilities and licensed facilities providing halfway house services shall have awake staff coverage 24 hours a day. Halfway houses shall have at least one staff person on the premises at all times.
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Observations
Based on a client interviews conducted on April 28, 2022 during a complaint investigation, the facility failed to ensure awake staff coverage 24 hours a day. All of the clients interviewed reported that the overnight staff in the C2 North rehabilitation and treatment unit fall asleep during overnight shifts.
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Plan of Correction
Overnight Shift Directors are responsible for ongoing monitoring of overnight unit staff in order to ensure awake staff coverage. Follow-up process was developed and is being conducted through routine monitoring (in person or via camera) and any findings addressed in the moment with any identified staff. Variances will also be reported to the Nursing and HR Manager for follow-up and will result in documented re-training and/or disciplinary action up to and including possible suspension and/or termination. |
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 of the detoxification unit and C2 North rehabilitation and treatment unit conducted on April 28, 2022 during a complaint investigation, the facility failed to maintain each bedroom in good repair.
The following bedrooms were found to not be in good repair at the time of the investigation:
C2 North
- Bedroom 243 had broken plexi glass over the window
- Bedroom 244 had peeling paint on the walls by both beds
- Bedroom 250 had a window with a missing window covering
Detoxification Unit
- Bedroom 003 smelled like cigarette smoke
- Bedroom 011 had a hole in the wall under the window
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Plan of Correction
The areas identified: broken plexiglass in room 243, peeling paint in room 244, hole in room 011, and missing window shade in room 250 were all addressed by 5/27/22. A search was conducted in 003, but client had been discharged and no contraband was found. Smoking is prohibited inside buildings on campus and when suspected the Shift Director (or designee) will trigger a search for any contraband which is then confiscated and disposed of by nursing personnel. The Therapist and Clinical Supervisors are responsible for addressing non-compliant behaviors and follow up with the client to address them as part of their treatment process. All maintenance issues identified are called into the Engineering's Facility Request line or submitted via email into their electronic ticket system and are dispatched/ addressed by the Office Manager in order of priority in coordination with the Property Manager. Maintenance issues called in will be reviewed daily by the Office Manager who will monitor and track any identified problems to ensure their resolution within a timely manner. Monthly EOC rounds will also be used to identify and report any similar areas of concern which will be reported to the Property Manager for resolution, and a summary of findings reported to leadership during monthly Safety Meeting. |
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 a physical plant inspection of the detoxification unit and C2 North rehabilitation and treatment unit conducted on April 28, 2022 during a complaint investigation, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The following bathrooms were found to not be functional, clean, or sanitary at the time of the inspection:
C2 North
-The bathroom in room 243 had chipped and peeling paint on the shower ceiling
-The bathroom in room 247 had chipped and peeling paint on the shower ceiling and on the wall by the sink
-The bathroom in room 249 had chipped and peeling paint on the shower ceiling
-The bathroom in room 251 had chipped and peeling paint on the shower ceiling
-The bathroom in room 250 had a dirty film and black mold-like substance on the shower walls and around the tub, holes in the wall and a cracked bathroom door
-The bathroom in room 253 had chipped and peeling paint above the sink, broken floor tiles, and an open hole where the drain cover was removed from the bathtub
-The bathroom in room 256 had a dirty film and black mold-like substance on the shower walls and around the tub
-The bathroom in room 252 had chipped and peeling paint over the window and a dirty film and black mold-like substance on the shower walls and around the tub
-The bathroom in room 246 had a dirty film and black mold-like substance on the shower walls and around the tub
-The bathroom in room 244 had a black mold-like substance around the sink
Detoxification Unit
-The bathroom in room 002 had a black mold-like substance around the bathtub
-The bathroom in room 004 had a black mold-like substance around the bathtub and a hole in the wall behind the toilet
-The bathroom in room 005 had a hole in the wall above the toilet paper holder
-The bathroom in room 007 had a black mold-like substance around the bathtub and a missing drain cover/stopper
-The bathroom in room 008 had a black mold-like substance around the bathtub/shower and a hole/missing caulk above the temperature water handle in the shower
-The bathroom in room 009 had a black mold-like substance around the bathtub and a brown substance that appeared to be fecal matter on the walls and ceiling. This was an unoccupied room that was supposed to be clean and ready for a new admission.
-The bathroom in room 010 had a black mold-like substance around the bathtub and hair on the shower walls. This was an unoccupied room that was supposed to be clean and ready for a new admission.
-The bathroom in room 011 had a black mold-like substance around the bathtub and shower and a hole in the wall under the window.
-The bathroom in room 013 had a black mold-like substance around the bathtub and shower and cracked tile on the shower wall.
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Plan of Correction
The peeling paint in bathrooms of 243, 247, 249, 251, 252 and 253 were addressed by 5/27/22. The bathrooms in rooms 002, 004, 007, 008, 009, 010, 011, 013 and 244, 246, 250, 252, 256 were also provided additional cleaning by 5/27/22 over the last several weeks by housekeeping staff utilizing a portable pressure washer to address identified issues in and around grout of shower/tub areas - cleaning continues to be an ongoing process throughout the facility and caulking is being replaced, as well, if and when identified as needed. Feedback by the Housekeeping Manager indicated that the substance in room 009 in particular was not fecal in nature, but rather food-based and the bathroom painted after being cleaned. Any damaged areas identified in rooms 004, 005, 011, and 013 were also addressed by 5/27/22, as well as missing drain covers in the tubs of rooms 007 and 253. The few remaining areas identified in rooms 008, 250 and 253 have an expected completion date by 6/7/22 (door and replacement tiles ordered and to be installed). Housecleaning is performed daily by housekeeping personnel and any areas of concern that may require additional cleaning service or attention above and beyond normal duties will be reported to the Housekeeping Manager who will follow-up and ensure resolution within a timely manner and a summary of findings reported to leadership during monthly Safety Meeting. All maintenance issues identified are called into the Engineering's Facility Request line or submitted via email into their electronic ticket system and are dispatched/ addressed by the Office Manager in order of priority in coordination with the Property Manager. Maintenance issues called in will be reviewed daily by the Office Manager who will monitor and track any identified problems to ensure their resolution within a timely manner. Monthly EOC rounds will also be used to identify and report any similar areas of concern which will be reported to the Property Manager for resolution, and a summary of findings reported to leadership during monthly Safety Meeting. |