INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 29, 2020 and February 12, 2020 by staff from the Division of Drug and Alcohol Program Licensure . Based on the findings of the on-site complaint investigation, Kirkbride Center, was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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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 January 29, 2020, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair for the well being of clients, staff, and visitors.
Findings:
Rooms 101, 005, 007, 009, and 011 were found to have broken windows.
Room 201 has a broken window, covered by a board.
Room 004 the wall where the window is located is being work on and clients are still living in the room, safety hazard.
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Plan of Correction
Under the responsibility of the acting Property Manager all windows in rooms identified in the findings (001, 005, 007, 009, 011, 201) were repaired, cleaned and new sealant added for additional insulation. Room 004 was also closed while repairs to the wall were conducted and which is now completed. Environment of Care (EOC) rounds, also under the responsibility of the acting Property Manager and Safety Officer, will be conducted monthly in order to identify and maintain the cleanliness, safety, sanitation, and good repair of the building and grounds on an ongoing basis per regulations, and any findings will be reviewed with leadership in monthly Safety Meeting.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on client interviews and the physical plant inspection, the facility faieds to provide cold water in room 501's bathroom and in room 530's bathroom hot water.
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Plan of Correction
Under the responsibility of the acting Property Manager the reported hot and cold water issues in the two rooms were examined by engineering staff and are currently working within designated parameters. They did identify that the hot water in particular (due to proximity to the boiler) did take slightly longer to heat up, but did work (and did not exceed 120F). If/when any issues arise, any problems with water pressure or temperature will be addressed on an as needed basis by engineering staff as directed by the acting Property Manager and any findings will be reviewed with leadership in monthly Safety Meeting. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
During a physical plant inspection conducted on February 12, 2020 around 12:20pm, the facility failed to ensure that the all cold foods are served at or below 40 degrees and all hot foods served at or above 140 degrees. The temperature reading on the hot food, chicken option, was reading at 130? and the alternative option of, tuna fish, was reading at 58.7?. Additionally, another temperature reading was conducted around 1:20 PM, the temperature reading on the alternative meal option of tuna fish was measured at 62?.
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Plan of Correction
Under the responsibility of the Food Services Manager, a vendor effected inspection and repair of the steamer bays (intended to keep hot food hot) which included recent recalibration of the temperature dials which are now working to maintain appropriate temperatures per regulations. Additionally, food services staff have been instructed to ferry only as much cold foods from the refrigerator at the beginning of each shift as is necessary for the number of clients who require it for that meal time in order to maintain appropriate temperatures for cold foods. Regular monitoring of temperatures for hot and cold foods will be conducted under the responsibility of the Food Services Manager to ensure compliance with regulations and any findings will be reviewed with leadership in monthly Safety Meeting. |
705.8 (1) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
Based on client interviews and a physical plant inspection, the facility failed to maintain an indoor temperature of at least 65F in the winter. Due to cold air coming in from the window in room 517 the temperature was not at least 65F during winter.
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Plan of Correction
Under the responsibility of the acting Property Manager and Safety Officer, the window in room 517 had new sealant applied to ensure no draft would escape into the room. Additionally, engineering determined that the louvers were found to be closed contributing to temperature maintenance issues and were opened and secured. Environment of Care (EOC) rounds, also under the responsibility of the acting Property Manager and Safety Officer, will be conducted monthly in order to help identify and maintain appropriate heating and cooling per regulations and any findings will be reviewed with leadership in monthly Safety Meeting. |