INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 20-23, 2008 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on November 26, 2008.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an inspection conducted on October 20-23, 2008, the facility failed to present, at the appointed time to the Department licensing representatives, the plan documenting the qualifications and training of staff.
Findings:
The facility did not provide documentation of the staff qualifications and training when initially requested. The facility did not provide the complete plan documenting the qualifications and training of staff until the final day of the inspection.
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Plan of Correction
1. The Human Resources will identify all employees who need the two required trainings within one year and those who need the trainings within two years. Development of the list will occur by February 28, 2009.
2. The six- and four-hour required trainings will be offered on a quarterly basis with about 25 employees requiring the trainings to be assigned to attend each quarter. This will continue during the first quarter of 2009 and continue quarterly.
3. The Director of Nursing is applying to the Bureau of Drug and Alcohol Programs to determine whether a facility employee may be trained to provide the required 10 hours of training.
4. Compliance will be monitored by the Director of Human Resources. |
704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of 16 personnel records on October 21, 2008, the facility failed to document a core curriculum training in clinical supervision provided by or approved by the Department for clinical supervisors who have not functioned for two years as a supervisor in the provision of clinical supervision in two of three records where required.
Findings:
The facility did not document two years of prior supervisory experience in the provision of clinical services or the core curriculum training in clinical supervision in personnel records # 3 and 12.
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Plan of Correction
1. The facility will seek a listing of the required core curriculum from the Bureau of Drug and Alcohol Programs to determine the next available date for the clinical supervision training in the Southeastern Pennsylvania area.
2. The Division of Drug and Alcohol Program Licensure will be notified upon the supervisor's completion of the training.
3. The Project Director will be responsible for achieving and maintaining compliance with this standard. |
704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of 16 personnel records on October 21, 2008, the facility failed to document monthly meetings with their new supervisors to discuss their duties and performance for the first six months of employment in that position in two of four records where required, #8 and 12..
Findings:
Personnel # 8 was placed in a supervisor position on 09/03/2008 but did not have documentation of monthly supervision.
Personnel # 12 was placed in a supervisor position on 08/25/2008 but did not have documentation of monthly supervision.
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Plan of Correction
1. The Project Director will facilitate monthly supervision for two new supervisors -- the Clinical Director and the Director of Social Services -- over the next six months.
2. Supervision topics will include assessment/re-assessment, documentation, state regulations and performance improvement.
3. The Project Director will maintain a binder -- signed by all three -- of minutes of each of the six required supervision sessions.
4. Copies of the supervision also will be maintained in the respective employees' personnel files. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of 16 personnel records on October 21, 2008, the facility failed to document the required qualifications or training for the position of counselor in two of 12 personnel records where required.
Findings:
The facility did not document the qualifications for the position of counselor in personnel records #4 and 14.
Personnel record # 4 documented a Certified Addiction Counselor certification, but the certification expired in January 2008.
Personnel Record # 14 documented a Bachelor ' s Degree but did not document at least one year of prior clinical experience.
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Plan of Correction
1. Employee #4 has contacted the Pennsylavnia Certification Board to obtain his current CAC certification. Upon receipt,the CAC certificate will be placed in the employee's personnel file.
2. Six months of direct and close supervision will be provided by the Clinical Director to employee #14.
3. Documentation of direct and close supervision will be placed in the personnel file of employee #14.
4. Compliance will be monitored by the Director of Human Resources. |
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
Based on a review of 16 personnel records, on October 21, 2008, the facility failed to document a written individual annual training plan in six of fifteen records where required.
Findings:
The facility did not document an annual individual training plan in personnel records # 5, 8, 11, 14, 15 and 16
Additionally, based on a review of administrative documentation and interviews with the project director on October 21, 2008, the facility failed to document a written individual annual training plan for many non-clinical employees.
Findings:
The facility did not document a written individual annual training plan in 19 of 19 personnel in the security department.
The facility did not document a written individual annual training plan in 10 of 10 personnel in the administrative department.
The facility did not document a written individual annual training plan in 22 of 22 personnel in the Dietary Department.
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Plan of Correction
1.Training plans will be developed with the start of the start of the next training year, which is July 1, 2009, through June 30, 2010.
2. The Director of Human Resources will provide the Project Director with a list of employees by May 1, 2009.
3. The list will include each employee's supervisor. The supervisor will be required to collaborate with their reports to develop individual training plans by June 30, 2009, the start of the next training year.
4. The Director of Human Resources and the Project Director will be responsible for monitoring compliance. |
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 16 personnel records, on October 21, 2008, the facility failed to document a minimum of six hours of HIV/AIDS and/or a minimum of four hours of tuberculosis/sexually transmitted diseases training in three of twelve records where required.
Findings: The facility did not document a minimum of six hours of HIV/AIDS and/or a minimum of four hours of tuberculosis/sexually transmitted diseases training in personnel records # 5, 7 and 15.
Personnel # 5 was hired on 02/20/2006 but did not have documentation of four hours of tuberculosis/sexually transmitted diseases training.
Personnel # 7 was hired on 05/17/2005 but did not have documentation of four hours of tuberculosis/sexually transmitted diseases training.
Personnel # 15 was hired on 10/22/2007 but did not have documentation of six hours of HIV/AIDS or four hours of tuberculosis/sexually transmitted diseases training within the first year of employment.
Additionally, based on a review of administrative documentation and interviews with the project director on October 21, 2008, the facility failed to document a minimum of six hours of HIV/AIDS and/or a minimum of four hours of tuberculosis/sexually transmitted diseases training for many non-clinical employees.
Findings:
The facility did not document, within the first two years of employment, six hours of HIV/AIDS or four hours of tuberculosis/sexually transmitted diseases training for 3 of 3 personnel in the security department where required.
The facility did not document, within the first two years of employment, six hours of HIV/AIDS or four hours of tuberculosis/sexually transmitted diseases training for 4 of 4 personnel in the administrative department where required.
The facility did not document, within the first two years of employment, six hours of HIV/AIDS or four hours of tuberculosis/sexually transmitted diseases training for 11 of 11 personnel in the Dietary Department where required.
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Plan of Correction
1. The Human Resources will identify all employees who need the two required trainings within one year and those who need the trainings within two years. Development of the list will occur by February 28, 2009. 2. The six- and four-hour required trainings will be offered on a quarterly basis with about 25 employees requiring the trainings to be assigned to attend each quarter. This will continue during the first quarter of 2009 and continue quarterly. 3. The Director of Nursing is applying to the Bureau of Drug and Alcohol Programs to determine whether a facility employee may be trained to provide the required 10 hours of training. 4. Compliance will be monitored by the Director of Human Resources. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Follow-up information.
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Observations
Based on a review of six inpatient psychiatric client records on October 22-23, 2008, the facility failed to document follow-up information in three of three client records where required.
Findings:
The facility did not document follow up information within one week of discharge as stated in the project ' s policy and procedures manual in client records # 20, 21 and 22.
Client # 20 was discharged on 03/03/2008, but follow-up information was not documented at the time of this inspection.
Client # 21 was discharged on 03/14/2008, but follow-up information was not documented at the time of this inspection.
Client # 22 was discharged on 04/22/2008, but follow-up information was not documented at the time of this inspection.
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Plan of Correction
1. The Project Director and the Manager of Medical Records will develop a mechanism to better track those acute psychiatric patients with co-occurring disorders. These are a subset of the larger group of acute psychiatric patients. The purpose of identifying the subset is to ensure that those acute patients treated under the Department of Health/Department of Public Welfare licenses are identified as needing the seven-day follow-up.
2. The Project Director will meet December 2 with the Director of Social Services on the acute units together with the Clinical Director and Clinical Operations Supervisor for the Chemical Dependency Programs to develop a mechanism for documenting completion of the seven-day follow-ups for all patients with co-occurring disorders discharged from the acute psychaitric units. The Director of Social Services will be charged with ensuring compliance with the standard for acute psychiatric patients with co-occurring disorders.
3. The requirement of the seven-day follow-up for acute psychiatric patients will be added to the close chart audit tool used by Medical Records coordinators to review closed charts.
4. Results of the close-chart audits will be provided monthly to the Executive Committee for the acute psychiatric units (called Dashboard) for oversight and monitoring and to ensure compliance with the standard.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative documentation on October 20 -23, 2008 the facility failed to show that they obtained the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
Findings:
The facility did not document an audit of all financial activities for the fiscal year of July 1, 2006 to June 30, 2007. The last documented annual audit of all financial activities was for the fiscal year of July 1, 2005 to June 30, 2006.
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Plan of Correction
1. The audit is in process and leadership expects completion of the audit by March 31, 2009.
2. The President/Chief Executive Officer and the Chief Financial Officer are responsible for monitoring completion of the audit. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of 16 personnel records, on October 21, 2008, the facility failed to document a staff performance evaluation at least annually in four of ten records where required.
Findings:
The facility did not document a performance evaluation 90 days from date of hire and/or annually from date of hire, as stated in the project ' s policy and procedures manual, in personnel records # 5, 6, 7 and 11.
Personnel # 5 date of hire 02/20/2006, last performance evaluation 05/19/2006.
Personnel # 6 date of hire 04/21/2008, performance evaluation not completed.
Personnel # 7 date of hire 05/17/2005, last performance evaluation 05/17/2007
Personnel # 11 date of hire 09/22/2003, last performance evaluation 02/01/2006
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Plan of Correction
1. The Assistant Director of Nursing and the Nurse Educator/Infection Control Nurse will identify those employees in need of annual evaluations.
2. The annual evaluations will be completed by the Assistant Director of Nursing and the Nurse Educator/Infection Control Nurse.
3. Beginning in March 2007, the facility moved away from annual evaluations on individual employee's anniversary-of-hire dates. Instead, the Human Resources Department identified specific months during which specific departments would undergo annual evaluations.
4. The Director of Nursing will perform annual evaluations for all nurses in May 2009, according to the schedule of annual evaluations identified by the Human Resources Department.
5. The Director of Human Resources will ensure compliance for all nurses. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on an inspection of the facility ' s physical plant and self report on 10/22/2008, the facility failed to secure client record within locked storage containers.
Findings:
The facility did not secure active client records in a locked storage container.
The facility maintains client records on a cart in an unlocked room that is not used specifically to maintain client records.
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Plan of Correction
1. The facility presently secures the open medical records in an area that can be locked and is accessible only to staff. The area also includes a refrigerator and microwave.
2. In order to comply with this standard, the facility will engage in one of two remedies:
A. The existing chart room will remain as the chart and all non-charting equipment or appliances will be removed.
B. The chart room will move to a different location that can be locked and which will be dedicated only to charting activities.
3. The plan will be reviewed by the Executive Committee (internally called Dashboard) for oversight and monitoring.
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709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on an inspection conducted on October 20-23, 2008 the facility failed to demonstrate a data collection and record keeping system that allows for the efficient retrieval of data as needed.
Findings:
The facility did not retrieve information related to clients and staff in a timely manner throughout the duration of this inspection.
Staffing data was requested by the licensing specialist on the first day of inspection, but the requested information was received gradually throughout the four day inspection.
Client records were requested by the licensing specialist, but the facility retrieved only some of the requested records approximately thirty minutes later, and the others were provided approximately one hour after the initial request.
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Plan of Correction
1. The Project Director will ensure that all data/medical records are retrieved by staff in a timely fashion and that the facility meets expectations for data on the first day of each inspection. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of six inpatient detoxification client records on October 22-23, 2008, the facility failed to document a complete psychosocial evaluation in three of six records where required.
Findings:
The facility did not document a psychosocial evaluation to include a composite picture which identifies relationships, conditions and causes leading to the client ' s current situation in client records # 12, 13 and 15.
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Plan of Correction
1. The Clinical Director on a monthly basis reviews the quality of assessments/re-assessments in 10 percent of open records on a single day during the third week of each month.
2. The focus of the qualitative assessments is on spirituality, leisure activities and relapse history. The monthly qualitative audits will be expanded to include a composite picture of each patient that identifies relationships, and the conditions and causes leading to the patient's current situation.
3. The Clinical Director and the Clinical Operations Supervisor will continue to review the quality of overall assessments during weekly supervision sessions with primary therapists.
4. Results of the monthly assessments as well as the weekly supervision session will be reported monthly to the Executive Committee (internally called Dashboard) for oversight and monitoring.
5. The facility will continue to participate in case conceptualization trainings at the Institute for Cognitive Therapy in Philadephia. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of ten inpatient client records on October 22-23, 2008, the facility failed to document a complete psychosocial evaluation in seven of seven records where required.
Findings:
The facility did not document a psychosocial evaluation to include the client ' s needs or problems that can or cannot be resolved through treatment in client records #s 1, 2, 3, 4, 5, 6 and 7.
The facility did not document a psychosocial evaluation to include the client ' s assets, strengths or other factors that can contribute to the resolution of identified problems in client records #s 1, 2, 3, 4, 5, 6 and 7.
The facility did not document a psychosocial evaluation to include the client ' s potential/available support systems in client records #s 1, 2, 3, 4, 5, 6 and 7.
The facility did not document a psychosocial evaluation to include the client ' s negative factors that might affect treatment in client records #s 1, 2, 3, 4, 5, 6 and 7.
The facility did not document a psychosocial evaluation to include the client preferred coping mechanisms in client records #s 1, 2, 3, 4, 5, 6 and 7.
The facility did not document a psychosocial evaluation to include the counselor ' s conclusions regarding the client ' s attitude towards and ability to participate in treatment in client records # 1, 2, 3, 4, 5, 6 and 7.
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Plan of Correction
1. The Clinical Director on a monthly basis reviews the quality of assessments/re-assessments in 10 percent of open records on a single day during the third week of each month. 2. The focus of the qualitative assessments is on spirituality, leisure activities and relapse history. The monthly qualitative audits will be expanded to include a composite picture of each patient that identifies the patient's needs or problems that can or cannot be resolved through treatment. 3. The Clinical Director and the Clinical Operations Supervisor will continue to review the quality of overall assessments during weekly supervision sessions with primary therapists. 4. Results of the monthly assessments as well as the weekly supervision session will be reported monthly to the Executive Committee (internally called Dashboard) for oversight and monitoring. 5. The facility will continue to participate in case conceptualization trainings at the Institute for Cognitive Therapy in Philadephia. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of ten inpatient client records on October 22-23, 2008, the facility failed to document a complete treatment plan update in three of four records where required.
Findings:
The facility did not document a treatment and rehabilitation plan update to include an assessment of the client ' s progress in relationship to the stated goals of the comprehensive treatment plan in client records # 2, 5 and 6.
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Plan of Correction
1. The Clinical Director and the Clinical Operations Supervisor in weekly supervision sessions with primary therapists will review the requirement that treatment plan updates include a progress report on the status of goals and objectives from the previous treatment plan, typically the master treatment plan.
2. The Clinical Director and the Clinical Operations Supervisor will review updated treatment plans monthly with the primary therapists to ensure the treatment plan updates include a review of the patient's progress toward meeting previous treatment goals and objectives.
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709.53(a)(5) LICENSURE Progress Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of ten inpatient client records on October 22-23, 2008, the facility failed to document complete progress notes in four of seven records where required.
Findings:
The facility did not document group progress notes to include a comment relative to the client's response or participation in the group session in client records # 3, 4, 5 and 6.
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will review the current group note template to ensure that it provides both prompts and space for primary therapists to document each patient's response to group participation. If revisions to the template are necessary, the revised format will be completed by December 31, 2008, with staff training to follow prior to implementation.
2. The Clinical Director and the Clinical Operations Supervisor during weekly supervision sessions will review with primary therapists the requirement that patients' responses to group participation is included in all progress notes. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of ten inpatient client records on October 22-23, 2008, the facility failed to document a complete discharge summary in four of four records where required.
Findings:
The facility did not document a complete summary describing the services offered while in treatment in client records # 7, 8 and 10.
The facility did not document a complete summary describing the client ' s response to treatment in client records # 6 and 9.
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Plan of Correction
1. The Clinical Director and the Clinical Operations Supervisors will conduct a training for primary therapists in the proper documentation in discharge summaries.
2. The training will include a summary of services offered and the patient's response to treatment.
3. Compeltion of the training and an overview of the response to the training will be provided to the Executive Committee (internally called Dashboard) for oversight and monitoring. |