INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2021 through January 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site 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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705.5 (a) (3) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(3) A storage area for clothing.
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Observations
The facility failed to provide a storage area for a client's clothing in good repair. Based on a physical plant inspection, the dresser in bedroom #301 was broken, had a drawer missing, and a second drawer was falling apart.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The broken dresser was removed and a new dresser installed for the client on January 20, 2021. All maintenance issues identified are called into the Engineering's Facility Request line 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. |
705.5 (i) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(i) Each bedroom shall have a window with a source of natural light.
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Observations
The facility failed to ensure that each bedroom had windows with a source of natural light. Based on a physical plant inspection, the window blinds behind protective screens were closed and could not be opened because the knob to open the blinds were broken. This prevented natural light from coming into bedroom #'s 111, 201, 218, 317, 319, 402, 410, 503, 508, 515 and 516.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All the blinds listed in rooms # 111, 201, 218, 317, 319, 402, 410, 503, 508, 515 and 516 have been repaired so that the clients are able to open and close them at their discretion and work was completed on January 29th, 2021. All maintenance issues identified are called into the Engineering's Facility Request line 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. |
705.5 (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
The facility failed to ensure that they prohibited smoking in bedrooms. Based on a physical plant inspection, there was an odor of cigarette smoke in the bathrooms of bedroom #'s 006, 315, 402, 416, 418, 503, 510, 514, 516 and 518.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Consistent with existing non-smoking policy, notifications, and posted signs informing all residents of the ban of any nicotine-related products in the facility, all clients, their belongings, and packages are inspected in an effort to prevent contraband (cigarettes) making it into the facility. Clients are also offered Nicotine replacement options by medical staff to help curb any nicotine cravings. BHT staff will additionally report to the Shift Director if the smell of cigarette smoke is detected during routine rounds and a search conducted consistent with existing policy in an effort to identify and remove any nicotine-related contraband. |
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
The facility failed to ensure that there were slip-resistant surfaces in all showers. Based on a physical plant inspection, the slip-resistant strips were missing in the shower stall in bedroom #205.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
New slip-resistant strips were installed in room # 205 in North Building on Jan 28, 2021. All maintenance issues identified are called into the Engineering's Facility Request line 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
The facility failed to ensure that all bathrooms were maintained in a functional, clean, and sanitary manner. Based on a physical plant inspection, the following issues were found:
There were bathroom fixtures that had areas covered with rust in bedroom #'s 201, 212, 309, 414, 501, 502 and 503.
The baths/showers had areas covered with what appeared to be mold or mildew in bedroom #'s 303, 309, 420, 501, 503, 512 and 515.
The bath handrail was broken and hanging from the wall in bedroom #202.
There was graffiti on the bathroom door in bedroom #307.
The shower head was leaking water in bedroom #309.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The broken handrail in Room # 202 and the shower head leaking in Room # 309 have been fixed. Painters have repainted the bathroom Room # 307 door and removed all the graffiti from it. Environmental Services have cleaned Room #'s 201, 212, 309, 414, 501, 502, and 503 for rust around bathroom fixtures/vents. They have also been cleaned room #'s 303, 309, 420, 501, 503, 512, and 515 to get rid of any apparent mold or mildew from the bathroom areas. The facilities department has completed work to re-grout tiles, re-caulk around the tub, and replace fixtures/vents as required in room #'s 201, 212, 309, 414, 501, 502, 503, 303, 309, 420, 512, and 515 All the work mentioned above has been completed as of Feb 2, 2021. All maintenance issues identified are called into the Engineering's Facility Request line 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.
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709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to ensure that all consent to release information forms documented the name of the person to whom the disclosure was to be made to in two of fourteen client records.
Client #3 was admitted into the Inpatient Non-Hospital Detoxification level of care on January 1, 2021 and was active at the time of inspection. There was a consent to release information form signed and dated by the client on January 1, 2021; however, the consent form did not include the specific name of the person or agency to whom the disclosure was to be made.
Client # 10 was admitted into the Inpatient Non-Hospital level of care on August 15, 2020 and was active at the time of inspection. There was a consent to release information form signed and dated by the client on August 15, 2020; however, the consent form did not include the specific name of the person or agency to whom the disclosure was to be made.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Admission Manager has conducted a re-training of staff on Jan. 8th, 2021 regarding appropriate consent form documentation with all fields to be fully and accurately completed. Admission Manager will conduct random weekly audits of admission records for a period of 3 months to ensure that consent form documentation and any release of information is being adhered to, per regulations, and will conduct remediation with staff upon any findings. Compliance Analyst will also conduct random monthly validation audits. Any variances identified will be brought to the attention of the Admissions Manager immediately for remediation, and findings discussed monthly in rehab dashboard meeting. |