INITIAL COMMENTS
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This report is a result of an on-site provisional license follow-up inspection conducted on April 13, 2023 through April 14, 2023 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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705.2 (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 April 13, 2023 between 9:30AM and 2:30PM, the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety.
The emergency exit stairwell, located in the Outpatient Maintenance area, had a doorway leading to the outside that was rusted through allowing visible light to be seen from the bottom corner and hindered the emergency exit door's opening.
This is a repeat citation from the December 1, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Since the previous survey the facility has recently hired a new Property Manager who is responsible for ongoing maintenance of the facility structures, etc. as per the cited regulation. Also, a dedicated Environment of Care (EOC) Coordinator was secured who is responsible for monitoring of the facility for compliance with EOC issues cited in these surveys. Work orders were submitted to the Property Manager and repairs have been completed to the exit door. The engineering Office Manager will report completed tickets to the EOC Coordinator who will inform 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. |
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 conducted on April 13, 2023 between 9:30AM and 2:30PM, 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 following areas were observed during the inspection, all of which pose a risk to the safety and well-being for clients, staff, and visitors.
- The doctor's office window, the window in conference room 103, the window on the entrance door to the center building, and the window by the Pool Area emergency exit had broken windowpanes.
- The community room, located in C2/North, had a broken window, which allowed for outside air to enter the room.
- There were exposed electrical/camera wires between group rooms 1 and 2 and above a double access door, both areas are in the Outpatient Maintenance area of the building.
- There was evidence of water damage and/or ceiling tile damage in the following locations:
-the N-O conference room, located in the Outpatient Maintenance area.
-the back-room area, located in the Detox area
-the N2 211 community bathroom
-the emergency exit area in the outpatient area
-the ceiling in room 503
-the N4 laundry room ceiling
-the wall by the N5 Nurses station, all of which had water damage or ceiling tile damage
- The bathrooms, located in the Detox area room 013 and C2/North room 253, had burned electrical outlets.
- There was trash located on the floors of the Detox lounge; the Detox room 004; the storage area for the fire extinguisher in the Outpatient Maintenance area; the elevator in the North Wing; the stairwell in the North Wing; the N1 community room; the N1 #107, N3 #317, room 215; and the facility elevators.
- There was a broken vent/panel located in C2/South #264 and a damaged air vent in room 515.
- There was a dead bug located on the floor in C3 #353.
- There was what appeared to be a mummified dead animal located in the emergency exit stairwell in the outpatient area.
- There was a broken cabinet drawer, located in the N2 recreational area.
- The laundry room in unit N2 had graffiti and the sink was leaking and dirty.
- The wall of the vestibule outside of unit N2 was peeling and in disrepair.
- There was a cord plugged in the wall that crossed the doorway to room 301, which created a tripping hazard.
- There was graffiti in rooms 402,407, 410, 503, 505, and the N3 Laundry room.
- There was a hole in the floor of the cafeteria that went through the subfloor and there was a hole in the bedroom wall in rooms 249 and 505.
- There was peeling paint on the window frame in room 283.
- There was a cracked windowsill in room 243.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the previous survey the facility has recently hired a new Property Manager who is responsible for ongoing maintenance of the facility structures, etc. as per the cited regulation. Also, a dedicated Environment of Care (EOC) Coordinator was secured who is responsible for monitoring of the facility for compliance with EOC issues cited in these surveys. Work orders have been submitted to the Property Manager to address and resolve all the identified issues cited under this regulation. The following bulleted items have already been resolved as of 5/4/23 and any remaining items are currently in process of being addressed, repaired or replaced as needed: - The community room, located in C2/North, had a broken window.
- There were exposed electrical/camera wires between group rooms 1 and 2 and above a double access door, both areas are in the Outpatient Maintenance area of the building.
- Evidence of water damage on the wall or ceiling tiles by the N5 Nurses station
- There was a damaged air vent/panel in rooms 515 and 264.
- There was a dead bug located on the floor in C3 #353.
- There was a broken cabinet drawer, located in the N2 recreational area.
- The laundry room in unit N2 had graffiti
- There was a cord plugged in the wall that crossed the doorway to room 301, which created a tripping hazard. regarding the doorway - emergency exit stairwell in the outpatient area was cleaned - There was trash located on the floors of the Detox lounge; the Detox room 004; the storage area for the fire extinguisher in the Outpatient Maintenance area; the elevator in the North Wing; the stairwell in the North Wing; the N1 community room; the N1 #107, N3 #317, room 215; and the facility elevators. The engineering Office Manager will report completed tickets to the coordinator and 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. Monitoring of completion conducted by the EOC Coordinator, and any variances identified reported to the Property Manager and/or Service Master Manager for remediation and to Kirkbride senior leadership [President/CEO and Board Directors] for monitoring of vendor performance. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection conducted on April 13, 2023 between 9:30AM and 2:30PM, the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers.
There was a bag of garbage sitting on the floor of the vestibule area outside of the elevators and unit N3.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility recently ended the contract with the old environmental services group and contracted with a new vendor which started May 1st. Their on-site Manager is responsible for managing the cleaning schedule and staffing in order to maintain the cleanliness or sanitation of the facility. All items identified have since been removed by the new cleaning staff who are responsible for any ongoing removal of any identified garbage when/where indicated on a daily basis as a function of their normal cleaning schedule. Monitoring of completion conducted by the EOC Coordinator, and any variances identified reported to the new vendor Manager for remediation and to Kirkbride senior leadership [President/CEO and Board Directors] for monitoring of vendor performance. |
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 conducted on April 13, 2023 between 9:30AM and 2:30PM, the facility failed to maintain living room and lounge furnishings in a state of good repair.
The lounge area of unit N3 had cracked and ripped couch cushions and the lounge area of unit
N5 had a table with a cracked and ripped surface.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the previous survey the facility has recently hired a new Property Manager who is responsible for ongoing maintenance of the facility structures, etc. as per the cited regulation. Also, a dedicated Environment of Care (EOC) Coordinator was secured who is responsible for monitoring of the facility for compliance with EOC issues cited in these surveys. Work orders were submitted to the Property Manager to address and resolve the identified issues and the table on N5 was removed and a new one ordered to replace it. The couch cushions on N5 are also in process to be switched out as soon as new ones are on-site. The engineering Office Manager will report completed tickets to the EOC Coordinator who will inform 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. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on April 13, 2023 between 9:30AM and 2:30PM, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
There was a group counseling session being conducted in room 121 with the door open that could be seen and heard from outside the counseling room.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Primary Therapist is responsible for maintaining confidentiality during individual and group sessions. Therapist in room 121 was counseled about this by the Program Director who has also communicated and reinforced this regulation with all clinical staff. Additionally, signage has been created and posted for offices where group counseling may occur as a notice and reminder that doors are to remain closed "while in session". Clinical Managers will conduct random audits for 60 days to monitor compliance and will report any variances monthly to rehab dashboard for review and follow-up with any remediation as needed. |
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 a physical plant inspection conducted on April 13, 2023 between 9:30AM and 2:30PM, the facility failed to provide paper towels or a mechanical dryer in each bathroom.
There were no paper towels or functional mechanical dryers in the bathrooms in rooms 101, 213, 247, 256, 416, 418, and the common bathroom outside of unit N5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the previous survey the facility recently ended the contract with the old environmental services group and contracted with a new vendor which started May 1st. Their on-site Manager is responsible for managing the cleaning staff duties including the upkeep of paper towel dispensers throughout the facility and the areas identified have since been addressed, and they will continue to maintain them as a function of their normal, day-to-day services as needed. Monitoring of completion conducted by the EOC Coordinator, and any variances identified reported to the new vendor Manager for remediation and to Kirkbride senior leadership [President/CEO and Board Directors] for monitoring of vendor performance. |
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 April 13, 2023 between 9:30AM and 2:30PM, the facility failed to provide slip-resistant surfaces in all bathtubs and showers.
There were no slip resistant surfaces in the shower in room 114.
This is a repeat citation from the January 7, 2021, December 3, 2021, and December 1, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the previous survey the facility has recently hired a new Property Manager who is responsible for ongoing maintenance of the facility structures, etc. as per the cited regulation. Also, a dedicated Environment of Care (EOC) Coordinator was secured who is responsible for monitoring of the facility for compliance with EOC issues cited in these surveys. Work orders were submitted to the Property Manager to address and resolve the identified issue and slip resistant surfaces are in place in the identified room. Monitoring of completion conducted by the EOC Coordinator, and any variances identified during EOC rounding reported to the Property Manager for remediation and to Kirkbride senior leadership [President/CEO and Board Directors]. |
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 April 13, 2023 between 9:30AM and 2:30PM, the facility failed to ventilate each toilet and washroom by an exhaust fan or a window.
The bathroom exhaust fans in unit C2 South and in rooms 011, 243, 249, 251, 256, 269, 271, 288, 289, 303, and 518 were not operable and there were no operable windows in the bathrooms.
This is a repeat citation from the December 1, 2022 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the previous survey the facility has recently hired a new Property Manager who is responsible for ongoing maintenance of the facility structures, etc. as per the cited regulation. The Property Manager identified a belt on a motor in one of the building fans that required replacing and changed it out within 48 hours of the survey. The facility property personnel checked the room exhaust vents in the identified rooms and determined that the Center Building exhaust systems are now functioning. Property personnel will continue to test the exhaust system on a routine, preventative maintenance schedule for ongoing monitoring and make sure it is working properly. Kirkbride senior leadership [President/CEO and Board Directors] will also contract with an independent third-party mechanical engineer to review the exhaust building systems to confirm our findings and make any identified improvements, as well as identify and address problems to the remaining 3 isolated rooms in the North Building that were identified during the survey. |
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 a physical plant inspection conducted on April 13, 2023 between 9:30AM and 2:30PM, the facility failed to provide toilet paper at each toilet at all times as there was no toilet paper in client bathroom numbers 106, 411 and room 415.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility recently ended the contract with the old environmental services group and contracted with a new vendor which started May 1st. Their on-site Manager is responsible for managing the cleaning staff duties including the upkeep of toilet paper throughout the facility and the areas identified have since been addressed, and they will continue to maintain them as a function of their normal, day-to-day services as needed. Monitoring of completion conducted by the EOC Coordinator, and any variances identified reported to the new vendor Manager for remediation and to Kirkbride senior leadership [President/CEO and Board Directors] for monitoring of vendor performance. |
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 April 13, 2023 between 9:30AM and 2:30PM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
- The bathroom in client bedrooms 346 and 348 had broken drywall.
- The bathroom in client bedroom 243 had peeling paint.
- The bathroom in client bedroom 230 had water damage.
- The common bathroom in room 207 had a broken light cover.
- The bathrooms in client bedrooms 003,006, 106, 201, 203,204, 206, 207, 211, 215, 216, 244, 266, 268, 270, 281 ,282, 284, 285, 286, 288, 291, 302, 304, 313, 314, 317, 319, 320, 353, 401, 403, 405, 409, 411, 412, 414, 416, 418, 426, 505, 509, 512, 513, 514, 515, 518 and 520 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 bathrooms in client bedrooms 003, 112, 203, 207, 211, 244, 246, 253, 269, 270, 271, 280, 282, 284, 285, 286, 288, 291, 293, 302, 304, 313, 317, 319, 320, 401, 402, 414, 420, 426, 503, 504, 506, 512, 515and 518 had dirt/grime and/or cigarette butts/ashes in the toilets.
- The community bathroom located in C2/South had what appeared to be dirt/grime and/or cigarette butts/ashes in the toilets.
- the men and women's outpatient bathrooms had what appeared to be mold or mildew in the exhaust fan vents.
- The common bathroom outside of unit N5 had what appeared to be dirt and grime on the floor.
- The bathrooms located in client bedrooms 270 and 285 had broken/leaking shower faucets.
- The bathroom located in client bedroom 013, 101, 112 had broken/leaking sink faucet.
- The bathroom located in client bedroom 285 had a broken vent panel.
- The bathrooms located in client bedrooms 008, 112, 301, 313, 415, 520 and 731 had graffiti on the wall and/or mirrors.
- There was graffiti in the men's outpatient bathroom, the women's outpatient bathroom and the common bathroom outside of unit N3.
- The bathroom located in client bedroom 317 had a broken bathroom door.
- The bathroom located in client bedroom 515 had a broken bathroom door handle.
- The women's community bathroom, located in the Outpatient Maintenance area, had an open junction box/access panel exposing an electrical wire.
- The bathroom in room 110, 266, 268 and 405 had broken or missing tiles.
- There were broken and rusted out bathroom stall doorframes in the men's outpatient bathroom, and the bathrooms labeled as 731 and 213.
- The bathroom located in client bedroom 202, 204 and 508 and had burned and melted electrical sockets.
This is a repeat citation from the January 7, 2021, December 3, 2021, and December 1, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Since the previous survey the facility has recently hired a new Property Manager who is responsible for ongoing maintenance of the facility structures, etc. as per the cited regulation. The facility also recently ended the contract with the old environmental services group and contracted with a new vendor which started May 1st. Their on-site Manager is responsible for managing the cleaning staff duties. Also, a dedicated Environment of Care (EOC) Coordinator was secured who is responsible for monitoring of the facility for compliance with EOC issues cited in these surveys. Aside from normal day-to-day cleaning by housekeeping staff, the Property Manager has requested that the new vendor Manager to assess the mold/mildew situation to determine if a specialty cleaning approach and/or use of a sealant or grout/caulking replacement approach is appropriate for a more permanent solution and develop an implementation schedule as appropriate. Work orders have been submitted to the Property Manager to address and resolve all the identified issues cited under this regulation. The following areas have already been resolved and any remaining are currently in process of being addressed: - The bathroom in client bedroom 230 had water damage.
- The common bathroom in room 207 had a broken light cover. - The bathrooms in rooms 270 and 285 had broken, leaking shower faucets.
- The bathroom located in client bedroom 013, 101, 112 had broken/leaking sink faucet.
- The bathroom located in client bedroom 285 had a broken vent panel.
- There was graffiti in the men's outpatient bathroom, the women's outpatient bathroom and the common bathroom outside of unit N3.
- The bathroom located in client bedroom 515 had a broken bathroom door handle.
- The women's community bathroom, located in the Outpatient Maintenance area, had an open junction box/access panel exposing an electrical wire.
- The bathrooms in room 110 and 405 had broken or missing tiles. The engineering Office Manager will report completed tickets to the coordinator and 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. Monitoring of completion also to be conducted by the EOC Coordinator and any variances identified reported to the new vendor Manager for remediation and to Kirkbride senior leadership [President/CEO and Board Directors] for monitoring of vendor performance. |
705.7 (b) (4) 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:
(4) Ensure that storage areas for foods are free of food particles, dust and dirt.
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Observations
Based on a physical plant inspection conducted on April 13, 2023 between 9:30AM and 2:30PM, the facility failed to ensure that storage areas for foods are free of food particles, dust, and dirt.
There was spilled milk in the large refrigerator and there was a bag of grits that was torn open spilling onto the floor with a dead roach on top in the pantry.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Food Service Director is responsible for the running and management of the cafeteria area and was informed of the citation and the identified concerns in the areas identified were cleaned. Moving forward, the EOC Coordinator will monitor along with routine EOC rounding to ensure compliance and any variances will be relayed to the Food Service Director for immediate resolution and Kirkbride senior leadership [President/CEO and Board Directors] for monitoring of vendor performance. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection conducted on April 13, 2023 between 9:30 AM and 2:30 PM, the facility failed to store all food items off the floor as there were cans of food and snack bags of food sitting on the floor of the pantry.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Food Service Director is responsible for the running and management of the cafeteria area and was informed of the citation and addressed the identified concerns and all food items are no longer stored on the floor. The EOC Coordinator will monitor along with routine EOC rounding to ensure compliance and any variances will be relayed to the Food Service Director for immediate resolution and Kirkbride senior leadership [President/CEO and Board Directors] for monitoring of vendor performance. |
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 April 13, 2023 between 9:30AM and 2:30PM, the facility failed to ensure that all heaters were permanently mounted or installed as there was a space heater located in counseling office 703, 221, N2 BHT desk and counseling office in N4.
This is a repeat citation from the December 1, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The space heaters were removed from the identified areas and the Program Director and Nursing Managers have followed-up with the identified staff for remediation and education of the regulation with instructions to comply or face further action. Unit Managers will continue to 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 by the EOC Coordinator monthly to senior leadership [President/CEO, Board Directors] for review and follow-up with staff as needed. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
Based on a physical plant inspection conducted on April 13, 2023 between 9:30AM and 2:30PM, the facility failed to limit smoking to designated smoking areas.
There were cigarette butts/ashes within several areas of the facility including the stairwell between floors C2 and C3, the exterior walkway from the kitchen to the main building, room 213, room 261, the common bathroom in unit N2, and the common bathroom in unit C2 East.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
From point of admission all clients are informed of our smoking policies and designated areas (outside the buildings) and clients are also offered Nicotine replacement options by medical staff to help curb any nicotine cravings. If the smell of cigarette smoke is detected during routine rounds, BHT staff are responsible for conducting a search with existing policy in an effort to identify and remove any contraband (lighters, matches, etc...). In addition, any clients discovered by staff in flagrante delicto of our smoking policies in non-designated areas will trigger an administrative discharge process for non-compliance with facility rules. Any such findings will be reported in writing to the Shift Director and clinical managers for follow-up. |
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
Based on a physical plant inspection conducted on April 13, 2023 between 9:30AM and 2:30PM, the facility failed to secure hard copy client records within locked storage containers. There were several active client records on a pushcart, which was located at the reception desk of the Pool Area. Additionally, there were loose client-related paperwork located on the desk of counselor office 221, which was unoccupied at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have ordered a locked storage container for the purposes of keeping records secure when in the Pool Area. Staff member responsible for transferring patient records to the "Pool Area" was counseled by the Program Director to maintain patient records in this locked storage container until requested by the physician and to return them there upon completion. Counselor for office 221 was also counseled by the Program Director that any loose documentation with identifiable PHI must be filed in the client's chart which is maintained in a locked storage area. Clinical Managers 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. |
709.28 (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
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of seven client records reviewed.
Client #2 was admitted to the Outpatient Maintenance activity on March 1, 2023 and was active at the time of inspection. A release of information form to an emergency contact was signed and dated by the client on February 28, 2023; however, the name of the person, agency or organization was not documented on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Primary Therapist is responsible for completion of this documentation in the patient record and was counseled by the Program Director on appropriate consent form documentation. Therapist did follow up with Client #2 and completed a new consent in its entirety, verified by compliance. 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. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on a consent to release information form in one of seven client records reviewed.
Client #1 was admitted to the Outpatient Maintenance activity on January 12, 2023 and was active at the time of inspection. A release of information form to a transportation service was signed and dated by the client on January 11, 2023; however, the specific information to be disclosed was not documented on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Primary Therapist is responsible for completion of this documentation in the patient record and was counseled by the Program Director on appropriate consent form documentation. Therapist did follow up with Client #1 and completed a new consent in its entirety, verified by compliance. 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. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on a consent to release information form in one of seven client records reviewed.
Client #1 was admitted to the Outpatient Maintenance activity on January 12, 2023. A release of information form to a transportation service was signed and dated by the client on January 11, 2023; however, the purpose of the disclosure was not documented on the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Primary Therapist is responsible for completion of this documentation in the patient record and was counseled by the Program Director on appropriate consent form documentation. Therapist did follow up with Client #1 and completed a new consent in its entirety, verified by compliance. 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. |
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 document that each patient received an average of 2.5 hours of psychotherapy per month, during the patient's first 2 years in treatment, in one of seven patient records reviewed.
Patient #5 was admitted to the Outpatient Maintenance activity on June 17, 2022 and was discharged on March 31, 2023. The record had documentation that only 1 hour of individual psychotherapy services were offered during the month of February 2023.
This is a repeat citation from the December 1, 2022 annual licensing renewal 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 record of service and progress noting, along with documented times of services. Client case #5 is an inactive record, so no remediation can occur. However, therapist was met with for supervision by the Program Director and educated on regulatory standards and instructed to document "start" and "end" times on all individual and group note documentation, and additionally informed to document when these same services were offered, but client "refused" or did not comply. Compliance Analyst will conduct random audits for 60 days to monitor compliance with documentation of required hours and/or documentation of services offered but refused. Any variances will be reported monthly 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 an administrative review on April 13, 2023, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for not having slip-resistant surfaces in all bathtubs and showers were submitted and approved by the Department for the January 7, 2021, December 3, 2021, and December 1, 2022 annual licensing inspections. Not having slip-resistant surfaces in bathtubs and showers was again found to be a deficiency in the April 14, 2023 provisional follow-up 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 December 4, 2019, January 7, 2021 and December 3, 2021, and December 1, 2022 annual licensing inspections. Not maintaining each bathroom in a functional, clean, and sanitary manner at all times was again found to be a deficiency in the April 14, 2023 provisional follow-up licensing inspection.
This is a repeat citation from the December 1, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For the purposes of increased oversight and monitoring on plant-related environmental issues, a dedicated Environment of Care (EOC) Coordinator was secured who is responsible for monitoring of the facility for compliance with EOC issues cited in these surveys and ongoing reporting of any identified concerns and their redress to the Property Manager and Service Master Manager.
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 also recently ended the contract with the old environmental services group and contracted with a new vendor (Service Master) which started May 1st, and which is responsible for the cleanliness or sanitation of the facility.
Finally, the Property Office Manager will monitor the scheduled completion of the identified citations and verify that all related work orders have been addressed with the EOC Coordinator who will report both engineering and environmental issues requiring further remediation to senior leadership [President/CEO, Board Directors]. |