INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 20-23, 2008 licensure renewal inspection. The follow-up inspection was conducted on February 24, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 March 31, 2009.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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Plan of Correction
1. The Project Director and the Human Resources Director have reviewed the entire staff roster for all departments, both clinical and non-clinical, to determine which employees must have the required six-hour HIV/AIDS and the four-hour TB/STD training within one or two years.
2. Each employee identified on the list was assigned a number from 1 to 8, signifying when they will be designated to complete the trainings during the next four quarters.
3. The list identified those employees who, by position, have direct, indirect and casual contact with patients. The list excluded departments such as Medical Records, whose staff does not interact with patients.
4. The facility will offer the required trainings at least quarterly over the next two years in order to bring the facility into compliance with the required trainings.
5. The Director of Nursing, following consultation with the Pennsylvania Department of Health, Division of Drug and Alcohol Program Licensure, will begin offering the trainings to staff based upon the department-approved curriculum.
6. Compliance will be monitored by the Director of Human Resources and reported quarterly to the Executive Committee, internally called Dashboard, for review. |
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
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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Plan of Correction
1. The Project Director and the Human Resources Director have reviewed the entire staff roster for all departments, both clinical and non-clinical, to determine which employees must have the required six-hour HIV/AIDS and the four-hour TB/STD training within one or two years. 2. Each employee identified on the list was assigned a number from 1 to 8, signifying when they will be designated to complete the trainings during the next four quarters. 3. The list identified those employees who, by position, have direct, indirect and casual contact with patients. The list excluded departments such as Medical Records, whose staff does not interact with patients. 4. The facility will offer the required trainings at least quarterly over the next two years in order to bring the facility into compliance with the required trainings. 5. The Director of Nursing, following consultation with the Pennsylvania Department of Health, Division of Drug and Alcohol Program Licensure, will begin offering the trainings to staff based upon the department-approved curriculum. 6. Compliance will be monitored by the Director of Human Resources and reported quarterly to the Executive Committee, internally called Dashboard, for review. |
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
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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Plan of Correction
1. The Project Director and the Manager of Medical Records will developa mechanism tobetter 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 treateted under the Department of Health/Department of Public Welfare licenses are identified as needing the seven-day follow-up.
2. The requirementof the seven-day follow-up for acute psychiatric patients will be added to the closed chart audit tool used by Medical Records coordinators to review closed charts.
3. Results of the closed-chart audits will be provided monthly to the Executive Committee for the acute psychiatric units, internally called Dashboard, for oversight and monitoring and to ensure compliance with the standard. |
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
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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Plan of Correction
1. Completion of the audit for fiscal year 2006-2007 has been delayed. The audit is in process and leardership expects completion of the audit by May 31,2 009.
2. The President/Chief Executive Officer and athe 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
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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Plan of Correction
1. The Assistant Director of Nursing and the Nurse Educator/Infection Control Nurse will identify those nrusing staff members still 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 employees' 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
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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Plan of Correction
1. The facility presently secures open medical recrods in an area that is locked and that is accessible only to staff.
2. On December 30, 2008, the Facility Director oversaw the removal of all non-chart materials from the chart room. This included a refrigerator, coffee maker and microwave oven.
3. The Facility Director is responsible for ensuring that all non-chart related items remain out of the chart room. |
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
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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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, relapse history, pain management and compliance with the facility's psychometric measures and incorporation of results into treatment planning documentation.
3. The monthly qualitative audits will be expanded to include a composite picture of each patient that identifies relationshp and the conditions and causes leading to the patient's current situation.
4. The Clinical Director and the Clinical Operations Supervisor will continue to review the quality of overall assessments during weekly supervisions sessions with primary therapists.
5. Results of the assessments as well as the weekly supervision sessions will be reported monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring.
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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
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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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, relapse history, pain management and compliance with the facility's psychometric measures and incorporation of results into treatment planning documentation.
3. 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.
4. The Clinical Director and the Clinical Operations Supervisor will continue to review the quality of overall assessments during weekly supervisions sessions with primary therapists.
5. Results of the assessments as well as the weekly supervision sessions will be reported monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring.
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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
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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Plan of Correction
1. The Clinical Director and the Clinical Operations Supervisor in weekly supervision sessions 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. Teh Clinical Director of the Clinical Operations Supervisor will review updated treatmetn plans monthly with the primary therapists to ensure the treatment plan updates include a review of the patient's progress toward meeting previous goals and objectives. |
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
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will review the current group 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 May 31, 2009, with staff training to follow priot to implementation.
2. The Clinical Director and teh 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
At time of review was unable to determine if facility followed the original plan of correction. Facility must resubmit original plan of correction.
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Plan of Correction
1. The Clinical Director and the Clinical Operations Supervisor 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. Completion of the training and an overview will be provided to the Executive Committee, internally called Dashboard, for oversight and monitoring. |