INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Buprenorphine and Methadone monitoring conducted on December 3, 2018 through December 6, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to provide documentation of an annual individual training plan for the current training year of July 1, 2018 through June 30, 2019 in 7 of 23 employee records reviewed
Employee # 3 was hired as a clinical supervisor on April 30, 2012.
Employee # 5 was hired as a clinical supervisor on September 21, 2009.
Employee # 6 was hired as a counselor on September 10, 2018.
Employee # 7 was hired as a counselor on June 25, 2018.
Employee # 10 was hired as a counselor on September 24, 2018.
Employee # 13 was hired as a counselor on September 7, 2016.
Employee # 16 was hired as a counselor on March 31, 2017.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
HR Director or designee is monitoring completion of all Individual Training Plans to ensure ongoing compliance, and has confirmed that the 7 individual training plans identified in the survey were completed and the correct forms are in use as of 12/12/18. Any such variances will be reported to management team in the rehab dashboard during the months of May-July. Clinical managers/ supervisors will sign documentation indicating their understanding of the process. Ongoing training will be provided to any newly assigned managers/supervisors and anyone that needs a refresher course. |
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
The facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training within the regulatory timeframe in one personnel record.
Employee #16 was hired as a counselor on March 31, 2017 and was due to have HIV/AIDS training no later than March 31, 2018. The HIV/AIDS training was not completed until September 7, 2018.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) will monitor ongoing monthly compliance with mandatory training sessions and due dates for all employees and review findings with department managers monthly. Failure to complete the identified trainings on the given date will result in staff's removal from the schedule. Any such variances will be reported monthly to management team for review in rehab dashboard meeting. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
The facility failed to ensure that the kitchen freezer's temperature was kept at or below 0 degrees Fahrenheit as the temperature was measured at 2 degrees Fahrenheit on December 6, 2018 at approximately 11:30 AM. Additionally, the freezer logs for December 1, 2018 through December 5, 2018 reported consistent temperatures above 0 degrees Fahrenheit.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Property Manager has followed up with engineering and dietary staff and the set point on the thermostat controller on the freezer was adjusted to lower the temperature on 12/7/18 and is currently reading below '0' degrees Fahrenheit. Starting 12/12/18, monthly EOC rounds by engineering staff will use a separate EOC rounds sheet in the kitchen area for monitoring purposes and ensure compliance with temperature, as well as logging. Any variances identified will be reported to management team for review in monthly EOC/Safety dashboard meeting. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to ensure that all heaters in the facility were permanently mounted or installed as there was a space heater discovered in each of the following areas:
1.Group room 521
2.Methadone dispensing room
3.Group room 121
4.Counselor office 735
5.Counselor office 739
6.Admissions office
7.Physician office
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The space heaters have been removed from the identified areas and the Property Manager (or designee) will ensure that Monthly EOC rounds by engineering staff will also monitor for these items starting 12/12/18. Any variances identified will be reported to management team for review in monthly EOC/Safety dashboard meeting. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to ensure that all hard copy patient records were kept within locked storage containers as there was client-identifying information for multiple discharged clients' records discovered in counselor office room 123.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director followed up with the counselor in room 123 for training purposes on 12/3/18 regarding regulations for security of patient records and informed her that any record not being actively worked on by the counselor is to be returned ASAP to the secured/locked chart room and/or medical records department where it originated. This information was disseminated in writing to all counselors by the Clinical Supervisors on 12/12/18 for review and signed receipt. Random spot-audits will occur monthly by Clinical Supervisors to monitor adherence and findings reported monthly to management team for review in rehab dashboard meeting. |
709.28 (c) 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.
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Observations
The facility failed to document all of the required elements of the consent to release information forms in 8 of 19 client records reviewed.
Client #2 was admitted to the detox level of care on November 29, 2018 and was active at the time of inspection. There was a consent form with a purpose of funding signed and dated by the client on November 29, 2018; however, the consent form did not include the specific name of the organization.
Client #3 was admitted to the detox level of care on November 30, 2018 and was active at the time of inspection. There was a consent form to an insurance company signed and dated by the client on December 3, 2018; however, the consent form did not include the purpose of the disclosure of information.
Client #6 was admitted to the detox level of care on January 26, 2018 and was discharged on January 31, 2018. There was a consent form to an emergency contact signed and dated by the client on January 26, 2018; however, the form did not include the specific name of the person to whom the disclosure would be made to. Additionally, that same consent form listed one of the items to be disclosed as "other" with no specification of what other information would be released.
Client #9 was admitted to the detox level of care on January 26, 2018 and was discharged on January 31, 2018. There was a consent form to an emergency contact signed and dated by the client on January 26, 2018; however, the form did not include the specific name of the person to whom the disclosure would be made to. Additionally, that same consent form listed one of the items to be disclosed as "other" with no specification of what other information would be released.
Client #13 was admitted to the inpatient non-hospital level of care on October 21, 2018 and was active at the time of the inspection. There was a consent form to an emergency contact signed and dated by the client on October 21, 2018; however, the form did not include the specific name of the person to whom the disclosure would be made to.
Client #16 was admitted to the psychiatric hospital detox level of care on November 29, 2018 and was discharged on December 5, 2018. There was a consent form to an emergency contact signed and dated by the client on November 29, 2018; however, the form did not include the specific name of the person to whom the disclosure would be made to.
Client #17 was admitted to the psychiatric hospital detox level of care on November 18, 2018 and was an active at the time of the inspection. There was a consent form to an emergency contact signed and dated by the client on November 18, 2018; however, it did not include the specific name of the person to whom the disclosure would be made to.
Client #18 was admitted to the psychiatric hospital detox level of care on April 1, 2018 and was discharged on April 6, 2018. There was a consent form to an emergency contact and a consent form to a primary care provider, both signed and dated by the client on April 1, 2018; however, both consent forms did not include the specific name of the person or organization to whom disclosure would be made to.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Counselors with any identified open records were met with on 12/11/18 by the Clinical Director to review and rectify any missing elements of consent with their clients. The Admissions Manager and Clinical Supervisors have also reviewed the survey findings and regulation with their staff for training purposes to ensure they are all completing the required elements on the consent to release information form. This information was disseminated in writing by the Admissions Manager and Clinical Supervisors for review and signed receipt by their respective staff. Refresher trainings will occur for staff during Annual Training Fair.
*The Observation for records (#6 and #9) appear to be duplicate findings of the same chart.
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