INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on September 27, 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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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 a physical plant inspection, it was observed that the facility failed to be kept in good repair at all times for the safety and well-being of residents, employees and visitors as evidenced by the following:
Room 248 was missing plaster from the wall across from the window.
Rooms 302 and 304 had broken and bent window blinds.
Room 404 had window blinds laying on the windowsill and not hung on the window.
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Plan of Correction
The repairs to missing plaster in wall of room 248 were completed by 10/18/22 and the issues identified with the blinds in rooms 302 and 304, and the unhung blinds in room 404 were all addressed by 10/14/22. 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. 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 |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain furnishing in a state of good repair.
Unit N1 lounge area has worn and ripped furniture cushions.
Unit N2 lounge area has two chairs with worn and ripped seat cushions.
Unit N3 lounge has furniture cushion backs that are worn and ripped. It also has a card table with a ripped vinyl covering.
Unit N4 lounge has ripped and worn furniture cushions. It also has missing sofa cushions.
Unit N5 lounge is missing sofa cushions.
The lounge shared by units C2E and C2S has ripped and worn furniture cushions
Unit C2N lounge has ripped and worn furniture cushions
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Plan of Correction
The cushions on N4 were completely replaced from cushions the facility had in stock on 10/5/22. The card table on N3 was also replaced. The remaining cushions referenced on lounges N1, N2, N3, N5, C2N and C2S are receiving new covers which are currently on order and will be utilized upon their arrival - estimated completion/delivery time by the manufacturer is within 6-8 weeks (first 2 weeks of December). 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. 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. |