INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 4 through 7, 2010 licensure renewal inspection. The follow-up inspection was conducted on June 23 through 24, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Kirkbride Center 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(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
Based on a review of the policy and procedure manual and an interview with the project director, the facility failed to document an assessment of staff training needs, as required by regulation.
The findings include:
On October 4, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, the assessment forms will be distributed to each employee on June 1 or each year and then must be completed and turned in to their supervisor by June 15. The regulation requires an assessment of staff training needs to be completed as a component of a staff development program. The facility failed to document the completion of a staff training needs assessment in twelve out of sixteen records reviewed for the July 1, 2010- June 30, 2011 training year. A staff training needs assessment form was not documented in personnel records # 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, and 16.
This was still out of compliance at the time of the follow-up conducted on June 24, 2011.
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Plan of Correction
1. At the time of the one-site visit, the training survey of employees was in process,nine days later than the previous target completion date of June 15, 2011.
2. The survey of training needs has been completed and will form the basis of the annual training plan and the review of the 2010-2011 training year.
3. Once completed, the training plan will be provided to the chemical dependence Executive Committee, internally called Dashbaord, for oversight and monitoring. |
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 clock hours of annual training required for counselors in one of nine personnel records reviewed.
The findings include:
Eighteen personnel records were reviewed on October 4 through 5, 2010. Nine personnel records were counselors. One personnel record failed to document the 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 5.
The Project Director confirmed on October 5, 2010 that the counselor did not have the 25 clock hours of training for the 2009-20010 training year.
This was still out of compliance at the time of the follow-up conducted on June 24, 2011.
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Plan of Correction
1. The facility has developed its annual training year to coincide with its fiscal year, which is July 1 through June 30.
2. At the time of the on-site survey, the facility was completing its annual Training Fair, which awards a total of 18 credits to those who complete the training.
3. Completion of the training is required of all Primary Therapists.
4. All Primary Therapists have met the required 25 hours by June 30.
5. The Facility Director, who is responsible for ensuring Primary Therapists meet the required hours each year, will reported the status of each Primary Therapist at the end of each quarter. The report will be made to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
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 observation during a physical plant inspection, the facility failed to 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 findings include:
A physical plant inspection was conducted on June 23, 2011 at approximately 1:15 PM.
It was observed during the physical plant inspection that bedroom # 248 had marred walls and peeling paint.
Also, the window blinds was hanging off of the hinge in bedroom # 248.
In addition, the window blinds in bedroom # 268 were falling down.
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Plan of Correction
1. The maintenance work in bedroom #248 and bedroom #268 have been completed.
2. The housekeepers and Behavioral-Health Technicians have been instructed to report any maintenance issues immediately to the secretary for the Engineering and Maintenance Department, so that a work order can be initiated and the repair/maintenance work completed.
3. Monthly, environmental rounds are conducted by a team, including the Infection Control Nurse, for oversight and monitoring. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on observation during a physical plant inspection, conversations with maintenance staff, and the facility director, the facility failed to provide an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
In addition, the facility failed to provide residents with individual bars of soap (with labeled soap container.)
The findings include:
A physical plant inspection was conducted on June 23, 2011 at approximately 1:15 PM.
During the physical plant inspection a client used the restroom.
The client exited restroom # 266 requesting and stating that there was no hand soap or paper towels in the restroom.
The surveyor went into restroom # 266 which was labeled "community restroom."
The restroom did not have toilet paper, an operable soap dispenser or individual paper towel or a mechanical dryer.
The tech came to the restroom with one individual bar of soap, paper towels, and toilet paper.
The tech stated that this bathroom is a community bathroom and that residents from other units are allowed to use it; therefore, toilet paper, soap, and paper towels are kept at the front desk as a means of control and so that residents don't clog the toilet.
During the physical plant inspection a number of bathrooms were observed without toilet paper, an operable soap dispenser, and either individual paper towels or a mechanical dryer.
In bathroom # 110 the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer. In addition, the bathroom was observed with several individual bars of soap in the bathtub and on the sink.
In bathroom # 111 the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer. In addition, the bathroom was observed with several individual bars of soap in the bathtub and on the sink.
In bathroom # 112 the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer. In addition, the bathroom was observed with several individual bars of soap in the bathtub and on the sink.
In bathroom # 114 the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer. In addition, the bathroom was observed with several individual bars of soap in the bathtub and on the sink.
In bathroom # 116 the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer. In addition, the bathroom was observed with several individual bars of soap in the bathtub and on the sink.
In bathroom # 119 the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer. In addition, the bathroom was observed with several individual bars of soap in the bathtub and on the sink.
In bathroom # 248 the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer. In addition, the bathroom was observed with several individual bars of soap in the bathtub and on the sink.
In bathroom # 266 the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer. In addition, the bathroom was observed with several individual bars of soap in the bathtub and on the sink.
In bathroom # 268 the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer. In addition, the bathroom was observed with several individual bars of soap in the bathtub and on the sink.
In bathroom # 403 the facility failed to provide an operable soap dispenser and either individual paper towels or a mechanical dryer. In addition, the bathroom was observed with several individual bars of soap in the bathtub and on the sink.
The facility director interviewed two maintenance staff regarding the lack of paper towels in client restrooms, both maintenance staff stated that they were instructed to not provide paper towels in the restrooms as residents tend to clog the toilets.
They stated that paper towels are maintained and controlled at the front desk on each unit.
During the exit interview the project director stated that management was not aware that maintenance was instructed to not provide paper towels in the resident restrooms.
He stated that paper towels will be provided in all bathrooms effective immediately.
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Plan of Correction
1. In the past, the facility had decided against providing paper towels to residents as the paper towels were being placed in the toilets, ultimately causing blockage and flooding problems.
2. On the day of the inspection, paper towels were returned to each patient bedroom and the bathrooms are stocked daily with appropriate paper products.
3. At admission, the facility now provides each patient with a plastic soap holder (similar to those used for trips). Each holder is affixed with a colored dot -- red, blue, yellow or green -- to designate which patient the soap dish belongs to. Each resident's dresser is affixed with a colored dot, so that residents can determine their personal soap dish, because it is color-coded.
4. Compliance with the requirement will be incorporated into Environment of Care Rounds, conducted monthly. The results will be reported to the Patient Safety Committee monthly for four months for oversight and monitoring. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on observation during a physical plant inspection, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
The findings include:
A physical plant inspection was conducted on June 23, 2011 at approximately 1:15 PM.
The facility is required to provide slip-resistant flooring in all bathtubs and showers.
The bathtub in bedroom # 248 had a worn out slip-resistant surface; therefore it was not an effective slip-resistant surface.
This is a repeat citation. The facility was previously cited on October 7, 2010.
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Plan of Correction
1. The skid-resistant flooring in the bathtub in bedroom #248 has been replaced.
2. An examination of the skid-resistant materials in each of the patient bathrooms will occur monthly as part of environmental rounds, for the purpose of oversight and monitoring.
3. The results will be reported monthly for four months to the Patient Safety Committee for oversight and monitoring. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on observation during the physical plant inspection, the facility failed to provide toilet paper at each toilet at all times
The findings include:
A physical plant inspection was conducted on June 23, 2011 at approximately 1:15 PM.
During the physical plant inspection a client used the restroom.
The client exited restroom # 266 requesting and stating that there was no hand soap or paper towels in the restroom.
The surveyor went into restroom # 266 which was labeled "community restroom."
The restroom did not have toilet paper, an operable soap dispenser or individual paper towel or a mechanical dryer.
During the physical plant inspection a number of bathrooms were observed without toilet paper.
The facility failed to provide toilet paper at all times in bathroom # 110.
The facility failed to provide toilet paper at all times in bathroom # 116.
In addition, the ladies restroom located on the first floor was observed at 2:30 PM without toilet paper, two out of four stalls did not have toilet paper.
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Plan of Correction
1. Housekeepers and Behavioral-Health Technicians have been instructed to ensure that each bathroom is appropriately stocked with paper supplies.
2. The facility now provides color-coded soap dishes to all patients upon admission. Motion-detector soap dispensers will be installed in all patient bathrooms that are considered to be community restrooms.
3. The public restroom on the first floor will be checked four times daily to ensure there is a sufficient supply of paper products.
4. Environmental rounds, conducted monthly, will provide oversight and monitoring to ensure appropriate paper and soap products are provided. |
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 observation during a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The findings include:
A physical plant inspection was conducted on June 23, 2011 at approximately 1:15 PM.
The call box in the bathroom of room # 119 was coming off of the wall.
The facility director stated that the call box was fixed, but the residents recently broke the metal box to make a match for cigarettes.
Bedroom # 248 had peeling and chipped paint.
The facility director confirmed that the bedroom had peeling and chipped paint.
This is a repeat citation. The facility was previously cited on October 7, 2010
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Plan of Correction
1. The call box in room #119 was repaired. As of this date, the unused call box remains repaired.
2. The paint in room #248 has been repaired and repainted.
3. Housekeepers and Behavioral-Health Technicians have been instructed to report maintenance and repair issues immediately to the secretary for the Engineering/Maintenance Department, who will initiate a work order for the work to be completed.
4. For oversight and monitoring, environmental rounds are conducted monthly. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document psychosocial evaluations in seven of seven short-term detoxification client records.
The finding includes:
Twenty two client records were reviewed on June 23, 2011 through June 24, 2011. Psychosocial evaluations were required to be documented in seven short-term detoxification client records, #16, 17, 18, 19, 20, 21, 22.
Client record #16 and 18 failed to document a composite picture of the client, the client's problems/needs, assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
Client records #17 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, client's attitude towards treatment and the counselor conclusions/impressions.
Client record #19, 20, 21 failed to document a composite picture of the client, the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
Client record #22 failed to document a composite picture of the client, assets/strengths, support systems, coping mechanisms and negative factors that might inhibit treatment.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the October 4, 2010 through October 7, 2010 licensing inspection. The facility's plan of correction submitted on November 4, 2010 and approved on November 12, 2010 stated the following:
"1. The Management Team -- the Project Director, the Facility Director, the Clinical Director, the Clinical Operations Supervisor and the Lead Social Worker -- will initiate a project to revise the biopsychosocial template.
2. The template will ensure compliance with the requirement that it includes assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor's conclusions/impressions.
3. The Clinical Director will conduct a monthly audit for four months to ensure completion of the biopsychosocial evaluation of detox patients. The audit will be of 10 percent of patients admitted to the detox program each month.
4. Results will be presented to the Executive Committee, internally called Dashboard, for oversight and monitoring."
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will seek guidance from the Pennsylvania Department of Health, Division of Drug and Alcohol Program Licensure, on the proper development of the psychosocial evaluation.
2. Following the development of guidelines for the creation of the psychosocial assessemnt, a training for all detox counselors and primary therapists will be conducted. Part of the training will include sample psychosocial assessments determined to be accurate, complete and exemplary.
3. Following the training, psychosocial evaluations will be evaluated with the authors by the Clinical Director and the Clinical Operations Supervisor during routine group and individual supervision.
4. For a four-month period beginning in October 2011, a performance improvement project utilizing 50 discharged charts per month will be initiated.
5. Results of the audits of the psychosocial assessments will be provided to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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:
(8) Follow-up information.
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Observations
Based on a review client records, the facility failed to document follow-up information within the required time frame according to regulation and facility policy in two of two short-term detoxification records.
The findings include:
Twenty two records were reviewed on June 23, 2011 through June 24, 2011. Follow-ups were required in four short-term detoxification discharge records, #19, 20, 21 and 22. Per the facility's policy and procedure manual follow-ups will be completed within 7 days of the clients discharge date.
Client #20 was discharged on December 14, 2010; the follow-up documentation was completed it could not be determined when the follow-up was conducted as the date was not documented.
Client #21 was discharged on December 6, 2010; the follow-up documentation was completed but could not determine when the follow-up was conducted as the date of the follow-up was not documented.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the October 4, 2010 through October 7, 2010 licensing inspection. The facility's plan of correction submitted on November 4, 2010 and approved on November 19, 2010 stated the following:
"1. The Clinical Operations Supervisor will redesign the Follow-Up form to ensure that it includes a line to notate the date that the follow-up was conducted.
2. The Clinical Team -- the Project Director, the Facility Director, the Clinical Director and the Clinical Operations Supervisor -- will revise the policy governing follow-up to ensure that follow-up is conducted in three types of discharges:
1. Treatment Complete
2. AWOL (Absence without leave)
3. AMA (Against medical advise)
The policy will indicate that within seven days following an AWOL or AMA discharge that one call will be placed or one letter will be sent to the home of the patient as part of outreach. The policy also will state that in some cases of two other categories of discharges -- special circumstances and administrative -- that follow-up will not be conducted.
Special circumstances are cases in which external factors prevented the patient from completing treatment. This would include patients who are incarcerated following a meeting with criminal justice during treatment or cases in which agents come to the facility with a court order or bench warrant to take a patient away; or the death of a patient.
The new policy will be monitored through monthly audits by the Clinical Team. Results of the audits will be presented monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring.
Previously, the policy did not require -- but recommended -- follow-up for patients who were non-routine discharges such as AMAs. "
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Plan of Correction
1. The data on the follow-up forms has been restored by the Clinical Operations Supervisor so that it may be determined whether the call to the aftercare provider was completed within the required time frame.
2. The Clinical Operations Supervisor is responsible for ensuring the correct forms are in place.
3. The Clinical Operations Supervisor will perform a chart audit monthly for four months to ensure compliance. The results will be reported to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document psychosocial evaluations in fifteen of fifteen rehabilitation client records.
The finding includes:
Twenty two client records were reviewed on June 23, 2011 through June 24, 2011. Psychosocial evaluations were to be documented in fifteen rehabilitation client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14 and 15.
Client records #1, 3, 4, 5, 7, 9, 10, 11, 12, 13, and 14 failed to document the client's assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client records #2, 6, 8 and 15 failed to document a composite picture of the client, the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment, attitude towards treatment and the counselor conclusions/impressions.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the October 4, 2010 through October 7, 2010 licensing inspection. The facility's plan of correction submitted on November 4, 2010 and approved on November 8, 2010 stated the following:
"1. The Management Team -- the Project Director, the Facility Director, the Clinical Director and the Clinical Operations Supervisor -- will review the template for the psychosocial evaluation to ensure that it includes information on the following:
A. Patient's assets/strengths
B. Support Systems
C. Coping Mechanisms
D. Negative factors that might
inhibit treatment
E. Attitude toward treatment
F. The counselor's conclusions and
impressions.
2. Once completed, the psychosocial assessment will be the basis for a training of Primary Therapists.
3. Monthly for four months, the Clinical Director will audit 10 percent of open charts at the time of the audit to determine compliance with the revised psychosocial evaluation.
4. Results of the audits will be shared monthly for four months with the Executive Committee, internally called Dashboard, for oversight and monitoring."
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will seek guidance from the Pennsylvania Department of Health, Division of Drug and Alcohol Program Licensure, on the proper development of the psychosocial evaluation. 2. Following the development of guidelines for the creation of the psychosocial assessemnt, a training for all detox counselors and primary therapists will be conducted. Part of the training will include sample psychosocial assessments determined to be accurate, complete and exemplary. 3. Following the training, psychosocial evaluations will be evaluated with the authors by the Clinical Director and the Clinical Operations Supervisor during routine group and individual supervision. 4. For a four-month period beginning in October 2011, a performance improvement project utilizing 50 discharged charts per month will be initiated. 5. Results of the audits of the psychosocial assessments will be provided to the Executive Committee, internally called Dashboard, for oversight and monitoring. |