INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 30, 2022 through December 1, 2022 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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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
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff persons received the minimum of 6 hours of HIV/AIDS and/or at least 4 hours of TB/STD, and other health-related topics trainings within the regulatory time frame in three of thirty-one personnel records reviewed.Employee # 29 was hired as a behavioral health tech on October 5, 2020 and was due to have the HIV/AIDS training and the TB/STD training no later than October 5, 2022. However, both trainings were not completed as of the date of the inspection.Employee # 30 was hired as a behavioral health tech on November 18, 2019 and was due to have the TB/STD training no later than November 18, 2021. However, the TB/STD training was not completed as of the date of the inspection.Employee # 31 was hired as a behavioral health tech on September 23, 2019 and was due to have the HIV/AIDS training and the TB/STD training no later than September 23, 2021. However, both trainings were not completed as of the date of the inspection.This is a repeat citation from the December 3, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) will provide all new hires with a calendar of required trainings and due dates at point of hire and every calendar year (with updates as they may occur) and track completed trainings. Reminders will be sent to individual staff periodically, and at least 2 months prior to any due dates. Staff who do not complete the training requirement within the first 2 years of employment will be taken off the schedule. Any variances will be reported monthly for review in rehab dashboard meeting for ongoing monitoring and to address any variances not already remediated.
All identified employees in the citation were informed of the requirements and consequences of not completing the required trainings, as well as upcoming in-house training dates:
Employee #29 completed HIV/AIDs online and submitted verification on 12/12/22 ? informed of in-house TB/STD training scheduled on January 7th, 2023.
Employee #30 ? informed of in-house TB/STD training scheduled on January 7th, 2023.
Employee #31 ? informed of scheduled in-house training dates for both HIV/AIDs and TB/STD in January 2023 as well as optional online training for HIV/AIDs.
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection conducted on December 1, 2022 between 10:00 AM and 11:30AM, the facility failed to maintain all structures, fences, and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.The following items were observed during the inspection, all of which posed a health and/or safety hazard for the clients and staff:- The bedroom in room 250 had an exposed electrical box allowing for a possible electical shock hazard.- The bedroom in room 263 had ripped or torn carpet, allowing for a possible tripping hazard.- The bedroom in room 284 had a broken glass windowpane, allowing for cold, winter air to enter into the bedroom.- The community room located in C2/North had a broken window, allowing for cold, winter air to enter into the bedroom.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following areas identified in this citation have been addressed by 1/4/23:
- The electrical box in Room 250 has been repaired.
- The torn carpeting in Room 263 has been removed.
- The broken glass windowpane in Room 284 has been repaired.
- The broken window in the community room in C2N has been repaired.
The facility has created a new position for a dedicated Environment of Care (EOC) Coordinator. This individual will be responsible for ongoing monitoring of the facility for adherence with the regulations for the issues cited and ensure reporting of any identified concerns to the appropriate departments for redress and will submit tickets to the Property Manager. The Property Manager will assign work orders to the newly dedicated full-time maintenance person when appropriate for timely resolution. The engineering Office Manager will report completed tickets to the coordinator and generate ongoing reports to senior leadership [President/CEO and Board Directors] on identified problems and ongoing status updates regarding resolution and of any areas require their attention, support and/or intervention.
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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
Based on a physical plant inspection conducted on December 1, 2022 between 10:00 am and 12:15 pm, the facility failed to prohibit smoking and the use of candles in bedrooms.During the inspection, there were extinguished cigarette butts/ashes located in bedrooms 246, 284 and 287. Additionally, client bedroom 415 had three candles located in the bathroom, which is attached to the bedroom. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Searches were conducted in bedrooms 246, 284 and 287 for any contraband, but none was found. While found to have been decorative and no appearance of having ever been lit, the candles in room 415 were removed to be returned to the client upon discharge. Such items have also been added to the identified list of restricted items. From point of admission all clients, their belongings, and packages are inspected in an effort to prevent contraband making it into the facility and clients are offered Nicotine replacement options by medical staff to help curb any nicotine cravings. If the smell of cigarette smoke is detected during routine rounds by BHT staff this will trigger a search consistent with existing policy in an effort to identify and remove any contraband. Any such findings will be reported in writing to the Shift Director and clinical managers for follow-up. |
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 a physical plant inspection conducted on December 1, 2022 between 10:00 AM and 11:30 AM, the facility failed to ensure privacy in all showers and bathtubs by partitions, doors, or curtains. Additionally, the facility failed to provide slip-resistant surfaces in all bathtubs and showers. The bathroom in client bedroom 013 did not have a privacy shower curtain. Additionally, the communal shower, located in C2/South, did not have a slip-resistant surface.This is a repeat citation from the January 7, 2021 and December 3, 2021 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following areas identified in this citation have been addressed by 1/4/23:
- The privacy shower curtain in the bathroom of Room 013 has been installed.
- A slip resistant surface has been installed in the communal shower in C2/South.
The facility has created a new position for a dedicated Environment of Care (EOC) Coordinator. This individual will be responsible for ongoing monitoring of the facility for adherence with the regulations for the issues cited and will submit tickets to the Property Manager. The engineering Office Manager will maintain a log of these items and assign work orders to the newly dedicated full-time maintenance person and/or to the designated representative to the Environmental contractor as appropriate for timely resolution. The coordinator will continue to submit tickets as problems are discovered for any newly identified areas of concern as well as the status of any open engineering and environmental tickets that were filed. Finally, the Office Manager will generate ongoing reports to senior leadership [President/CEO and Board Directors] on identified problems and ongoing status updates regarding resolution and of any areas that require their attention, support and/or intervention.
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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on December 1, 2022 between 10:00 AM and 11:30 AM, the facility failed to ensure that each bathroom had proper ventilation by exhaust fan or windowThe bathroom exhaust fans located in bedrooms 261 and 263 of C2/South were not operable at the time of inspection. Additionally, the bathroom exhaust fans located in bedrooms 243, 244, 245, 247, 248, 249, 250, 251, and 252 of C2/North were not operable at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The bathroom exhaust fans in Rooms 261 and 263 of C2/South, and the bathroom fans in rooms 243, 244, 245, 247, 248, 249, 250, 251 and 252 of C2/North are being repaired by an outside contractor and are expected to be completed by 3/31/23.
Moving forward, the Infection Control Nurse, along with the new Environment of Care (EOC) Coordinator will also be responsible for ongoing monitoring of the facility for compliance with the issues identified and will report/submit tickets to the Property Manager who will assign work orders to the newly dedicated full-time maintenance person when appropriate for timely resolution. The engineering Office Manager will maintain a log of these items and assign work orders to the newly dedicated full-time maintenance person and/or to the designated representative to the Environmental contractor as appropriate for timely resolution. The coordinator will continue to submit tickets as problems are discovered for any newly identified areas of concern as well as the status of any open engineering and environmental tickets that were filed. Finally, the Office Manager will generate ongoing reports to senior leadership [President/CEO and Board Directors] on identified problems and ongoing status updates regarding resolution and of any areas that require their attention, support and/or intervention.
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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 conducted on December 1, 2022 between 10:00 AM and 11:30 AM, 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:- The bathroom in client bedroom 283 had a clogged sink.- The bathrooms in client bedrooms 004, 007, 009, 013, 008, 103, 107, 111, 115, 214, 243, 246, 247, 249, 252, 256, 261, 264, 266, 289, 301, 306, 315,406, 408, 415, 420, 501, 502, 503, 504, 506 and 516 had what appeared to be mold or mildew in the showers and/or bathtubs. - The community bathroom located in C2/South had what appeared to be mold or mildew in the bathtub.- The bathroom in client bedroom 253 had damaged drywall.- The bathrooms in client bedrooms 284, 286, 287 had dirt/grime and/or cigarette butts/ashes in the toilets. This is a repeat citation from the January 7, 2021 and December 3, 2021 annual licensing renewal inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following areas identified in this citation have been addressed by 1/4/23:
- The clogged sink in Room 283 has been cleared.
- The drywall in Room 253 has been repaired.
- Bedrooms 284, 286 and 287 have been cleaned of all dirt, grime and cigarette butts and ashes.
The old/mildew issues in bathrooms in Rooms 004, 007, 009, 013, 008, 103, 107, 111, 115, 214, 243, 246, 247, 249, 252, 256, 261, 264, 266, 289, 301, 306, 315, 406, 408, 415, 420, 501, 502, 503, 504, 506, 516 and C2/South are undergoing a two-prong solution:
First, CoreCare has hired a special outside cleaning company to undertake a deep steam cleaning of these rooms in the next two weeks.
Second, CoreCare has hired an outside contractor to (i) remove all of the existing caulk where mold/mildew has occurred, (ii) remove any remaining mold or mildew in the bathrooms, and (iii) replace the caulk with new mold resistant caulk to provide a permanent solution.
In order to prevent these issues from arising in the future the facility will have a checklist for the housekeeping crews to report any potential clogging, cleaning, drywall or mold/mildew issues whenever identified.
The Infection Control Nurse, along with the new Environment of Care (EOC) Coordinator will also be responsible for ongoing monitoring of the facility for compliance with the issues identified and will report/submit tickets to the Property Manager who will assign work orders to the newly dedicated full-time maintenance person when appropriate for timely resolution. The engineering Office Manager will maintain a log of these items and assign work orders to the newly dedicated full-time maintenance person and/or to the designated representative to the Environmental contractor as appropriate for timely resolution. The coordinator will continue to submit tickets as problems are discovered for any newly identified areas of concern as well as the status of any open engineering and environmental tickets that were filed. Finally, the Office Manager will generate ongoing reports to senior leadership [President/CEO and Board Directors] on identified problems and ongoing status updates regarding resolution and of any areas that require their attention, support and/or intervention. Reports will also be reviewed monthly in the Infection Control and EOC committees.
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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
Based on a physical plant inspection conducted on December 1, 2022 between 10:00 am and 12:15 pm, the facility failed to ensure that all heaters were permanently mounted or installed as there was a space heater located in counseling office 523 and another space heater in patient room 206.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The space heaters were removed at time of survey from the identified areas. Moving forward Unit Managers will be responsible for conducting periodic rounds from October 1st through March 30th every year to monitor for these items and remove any unauthorized heaters that do not comply with regulatory standards and counsel staff on same. Any variances identified will be reported monthly to senior leadership [President/CEO, Board Directors] for review and follow-up with staff as needed. |
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
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in four of twenty-one client records reviewed.Client #15 was admitted to the outpatient maintenance level of care on May 18, 2022 and was discharged on September 2, 2022. There was documentation of disclosures to a transportation service on May 3, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.Client #16 was admitted to the outpatient maintenance level of care on March 7, 2022 and was discharged on August 4, 2022. There was documentation of disclosures to a transportation service on March 18, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.Client #18 was admitted to the outpatient maintenance level of care on June 15, 2022 and was discharged on September 2, 2022. There was documentation of disclosures to a transportation service on June 16, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.Client #19 was admitted to the outpatient maintenance level of care on May 5, 2022 and was active at the time of inspection. There was documentation of disclosures to a transportation service on May 4, 2022; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Transportation services have been added to the consent form documentation and the document reviewed with the outpatient Primary Therapist who is responsible for completion of this documentation in the patient record. All currently "active" outpatient clients (includes only #15 and #19) have signed the consents, as will all new clients presenting to the program. Compliance Analyst will conduct random audits for 60 days to monitor compliance and will report any variances monthly to rehab dashboard for review. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of patient records, the facility failed to document that a copy of a client consent was offered to the client in six of twenty-one client records reviewed.Client #15 was admitted to the outpatient maintenance level of care on May 18, 2022 and was discharged on September 2, 2022. There was a release of information form to the funding source that was signed and dated by the client on May 5, 2022; however, there was no documentation that a copy of the consent form was offered to the client.Client #16 was admitted to the outpatient maintenance level of care on March 7, 2022 and was discharged on August 4, 2022. There was a release of information form to the funding source that was signed and dated by the client on March 8, 2022; however, there was no documentation that a copy of the consent form was offered to the client.Client #17 was admitted to the outpatient maintenance level of care on February 1, 2022 and was discharged on June 1, 2022. There was a release of information form to the funding source that was signed and dated by the client on February 1, 2022; however, there was no documentation that a copy of the consent form was offered to the client.Client #18 was admitted to the outpatient maintenance level of care on June 15, 2022 and was discharged on September 2, 2022. There was a release of information form to the funding source that was signed and dated by the client on June 15, 2022; however, there was no documentation that a copy of the consent form was offered to the client.Client #19 was admitted to the outpatient maintenance level of care on May 5, 2022 and was active at the time of inspection. There was a release of information form to the funding source that was signed and dated by the client on May 4, 2022; however, there was no documentation that a copy of the consent form was offered to the client.Client #21 was admitted to the outpatient maintenance level of care on May 5, 2022 and was active at the time of inspection. There was a release of information form to the funding source that was signed and dated by the client on September 19, 2022; however, there was no documentation that a copy of the consent form was offered to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The client consent form was reviewed with the outpatient Primary Therapist who is responsible for ensuring that all clients are offered a copy of their consent and documenting same. All currently active clients (including #15 and #19 - other cited client records were inactive at time of inspection - including #21 which is mistakenly noted as active) have been offered copies and documentation of same is in their records. Compliance Analyst will conduct random audits for 60 days to monitor compliance and will report any variances monthly to rehab dashboard for review and follow-up by Supervisor as needed. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to document the completion of an initial drug-screening analysis for each prospective patient or a random urinalysis at least monthly therafter in four of twenty-one patient records reviewed. Patient #18 was admitted to the outpatient maintenance level of care on June 15, 2022 and was discharged on September 2, 2022. There was no documented drug screen analysis, in the record, for the month of June 2022. Patient #19 was admitted to the outpatient maintenance level of care on May 5, 2022 and was active at the time of inspection. There was no documented drug screen analysis, in the record, for the month of June 2022. Patient #20 was admitted to the outpatient maintenance level of care on April 14, 2022 and was active at the time of inspection. There was no documented drug screen analysis, in the record, for the month of July 2022. Patient #21 was admitted to the outpatient maintenance level of care on May 5, 2022 and was active at the time of inspection. There was no documented drug screen analysis, in the record, for the month of May 2022. This is a repeat citation from the December 1, 2021 through December 3, 2021 annual licensing renewal inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is not possible to correct missed screens from prior months in the cases cited; however, moving forward, the Central Dosing Nurse for Outpatient will be responsible for completion of any initial and ongoing monthly urinalysis for those clients per stated regulation. In the event that a sample is unable to be obtained by the required date (for example, if the client does not show up at the clinic on the day the urinalysis occurs or is unable/unwilling to provide a sample) this will be documented in the client record and attempted follow-up will occur at the next available opportunity whenever possible. Compliance Analyst will conduct random audits for 60 days to monitor compliance and will immediately report any variances to the Nurse Managers as they are identified. Nurse Managers will be responsible for investigating and determining the cause for any missed screen and developing a timely plan of correction to address the issue and conduct appropriate follow-up with the Central Dosing Nurse for remediation, as needed. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient's first 2 years, 1 hour of which shall be individual psychotherapy, in six of twenty-one patient records reviewed. Patient #15 was admitted to the outpatient maintenance level of care on May 18, 2022 and was discharged on September 2, 2022. The record of service and progress notes documented that for the month of August 2022, there were two hours of psychotherapy provided to the patient. Patient #16 was admitted to the outpatient maintenance level of care on March 7, 2022 and was discharged on August 4, 2022. The record of service and progress notes documented that for the month of June 2022, there were two hours of psychotherapy provided to the patient.Patient #17 was admitted to the outpatient maintenance level of care on February 1, 2022 and was discharged on June 1, 2022. The record of service and progress notes documented that for the month of April 2022, there was one hour of psychotherapy provided to the patient.Patient #18 was admitted to the outpatient maintenance level of care on June 15, 2022 and was discharged on September 2, 2022. The record of service and progress notes documented that for the month of August 2022, there were two hours of psychotherapy provided to the patient.Patient #20 was admitted to the outpatient maintenance level of care on April 14, 2022 and was active at the time of inspection. The record of service and progress notes documented that for the month of May 2022, there was one hour of psychotherapy provided to the patient. Additionally, for the month of August 2022, there were two hours of psychotherapy provided to the patient. Patient #21 was admitted to the outpatient maintenance level of care on May 5, 2022 and was active at the time of inspection. The record of service and progress notes documented that for the month of June 2022, there was no hours of psychotherapy provided to the patient. Additionally, for the month of October 2022, there were two and a half hours of psychotherapy provided; however, there was only forty-five minutes of individual psychotherapy provided to the patient. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The outpatient Primary Therapist is responsible for documentation of record of service and progress noting, along with documented times of services. They were met with for supervision and educated on regulatory standards and instructed to document "start" and "end" times on all individual and group note documentation, as well as improve timely documentation and filing of their notes evidencing same. Compliance Analyst will conduct random audits for 60 days to monitor compliance with documentation of required hours and will report any variances monthly to rehab dashboard for review and supervisor will follow-up with any remediation as needed. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient in one of one applicable patient records reviewed. Patient #17 was admitted to the outpatient maintenance level of care on February 1, 2022 and was discharged June 1, 2022. The record did not include documentation that the program transferred the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient to the receiving narcotic treatment program. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The outpatient Primary Therapist is responsible for transmitting information upon patient transfer and was met with for supervision to review transfer procedures per the stated regulation and was instructed moving forward to document on the fax cover sheet each of the required elements identified that are being transmitted per the regulatory requirements and file the fax confirmation page in the client record for evidentiary purposes. Compliance Analyst will conduct random audits for 60 days to monitor compliance and will report any variances monthly to rehab dashboard for review and supervisor will follow-up with any remediation as needed. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every sixty days in four of seven client records reviewed.Client #16 was admitted to the outpatient maintenance level of care on March 7, 2022 and was discharged on August 4, 2022. The comprehensive treatment plan was completed on March 8, 2022 and the first update was due no later than May 8, 2022; however, the update was not completed prior to discharge. Client #17 was admitted to the outpatient maintenance level of care on February 1, 2022 and was discharged on June 4, 2022. The comprehensive treatment plan was completed on February 1, 2022 and the first update was due no later than April 1, 2022; however, the update was not completed prior to discharge. Client #18 was admitted to the outpatient maintenance level of care on June 15, 2022 and was discharged on September 2, 2022. The comprehensive treatment plan was completed on June 15, 2022 and the first update was due no later than August 15, 2022; however, the update was not completed prior to discharge. Client #21 was admitted to the outpatient maintenance level of care on May 5, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on May 5, 2022 and the first update was due no later than July 5, 2022; however, the update was completed on September 19, 2022. Additionally, the next update was due no later than November 19, 2022; however, the update was not completed at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The outpatient Primary Therapist is responsible for documentation of treatment and rehabilitation plans and services. The outpatient Primary Therapist was met with for supervision and the 4 records identified in the citation were discussed. All 4 are no longer "active" so no current remediation can occur in those specific records. Moving forward the therapist has been instructed to complete and file their documentation the same day documentation is due. In the event that the client is unavailable at the time the next treatment plan update is due they are still to complete the update, document the absence of the client, and file everything in the client record. Monitoring will occur monthly over the next 60 days by Compliance Analyst for compliance and any variances will be reported to rehab dashboard for review and supervisor will follow-up with any remediation as needed. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a physical plant inspection conducted on December 1, 2022 between 10:00 am and 12:15 pm, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for providing privacy in toilets, showers, and bathtubs and providing slip-resistant surfaces in all showers/bathtubs were submitted and approved by the Department for the January 7, 2021 and December 3, 2021 annual licensing inspections. The facility failed to provide privacy in toilets, showers, and bathtubs and failed to provide slip-resistant surfaces in all showers/bathtubs and was again found to be a deficiency in the November 30, 2022 through December 1, 2022 annual licensing inspection. Plans of correction for maintaining each bathroom in a functional, clean, or sanitary manner at all times were submitted and approved by the Department for the January 7, 2021 and December 3, 2021 annual licensing inspections. Maintaining each bathroom in a functional, clean, and sanitary manner at all times was again found to be a deficiency in the November 30, 2022 through December 1, 2022 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
In recognition of the importance of addressing the identified issues, facility leadership [President/CEO, Board directors] have created a new position for a dedicated Environment of Care (EOC) Coordinator. This individual will be responsible for monthly monitoring of the facility for compliance with EOC issues cited in these surveys and monthly reporting of any identified concerns and their redress to senior leadership [President/CEO, Board Directors].
Second, the facility has retained a full-time maintenance person dedicated exclusively to the facility and, working with the new coordinator, to promptly remedy any EOC concerns within their scope and ability to address. The Property Manager and senior leadership [President/CEO, Board Directors] will be notified immediately of any areas that may require additional support and remediation from the engineering department and/or outside contracting services.
The facility will create an inspection/review schedule for the housekeeping contractor to ensure that any concerns related to the cleanliness or sanitation of the bathrooms are identified and reported as problems are discovered to the EOC coordinator for monitoring and reporting purposes, as well.
Finally, the Office Manager will conduct a final survey and report to senior leadership [President/CEO, Board Directors] upon the scheduled completion of the identified citations with verification that all items have been addressed to the leadership's satisfaction and/or identify any areas requiring further remediation.
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