INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on November 1 - 4, 2016 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.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The Staffing Requirements Facility Summary Reports was reviewed on October 25, 2016, the facility failed to ensure that they employed sufficient full-time clinical supervisors for every eight full-time counselors or counselor assistants, or both. The facility currently employees two full-time clinical supervisor who supervises 32 employees bringing their FTE total to 31:2.
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Plan of Correction
We believed that current staffing patterns at the time of the audit were consistent with adherence to the regulations with a full clinical management team consisting of 4 full-time supervisors/directors, plus a part-time licensed psychologist sufficient to adhere to an 8:1 ratio. However, clarification from the auditor stated that our Clinical and Program directors, who also were designated as the Facility and Project Directors respectively, could not be considered as FTE Supervisors due to the dual titles/responsibilities, and thus could not be counted in the 8:1 ratio. To address this and prevent re-occurrence we are therefore transferring the "Facility Director" responsibilities and title from our Clinical Director as of 1/16/17 to the Program Director to avoid any perceived conflict of "full-time" supervisory status, and will hire an additional Supervisor for the remaining position. Position to be posted also by 1/16/17 by HR manager and filled ASAP. Our Program Director will therefore hold both Facility and Project Director roles and will not be responsible for supervisory duties of any counselor positions. |
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 personnel records and a review of the Staffing Requirements Facility Summary Report on November 1, 2016, the facility failed to develop an individual training plan for 64 employees.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Training plans that were due for the 64 employees identified are already being addressed and are estimated to be completed by 1/31/17. Completion of the training plans is the responsibility of nursing management/ supervisory staff. A running grid will be maintained and monitored by the HR manager and reported to respective nursing management monthly in order to maintain up-to-date individual training plans. Ongoing monitoring will occur for a period of no less than 3 months and any updates will be reported in monthly management meetings by HR to review status of the process and identify any variances. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the Staffing Requirement Facility Summary Report on December 1-2, 2016, the facility failed to ensure that all staff persons received a minimum of 6 hours HIV/AIDS training and at least 4 hours of TB/STD training in records #16, 17, 18, 19, 20, 21, 22, 23, 24, 25 and 26.
Employee # 16, a counselor was hired August 3, 2015. HIV/AIDS and TB/STD training were to be completed within the first year of employment or by August 3, 2016. The facility failed to document that employee # 16 completed HIV/AIDS and TB/STD as of the time of inspection.
Employee # 17, a counselor was hired May 11, 2015. HIV/AIDS and TB/STD training was to be completed within the first year of employment or by May 11, 2016. The facility failed to document that employee # 17 completed HIV/AIDS and TB/STD as of the time of inspection.
Employee # 18, a counselor was hired June 10, 2015. HIV/AIDS and TB/STD training was to be completed within the first year of employment or by June 10, 2016. The facility failed to document that employee # 18 completed HIV/AIDS and TB/STD as of the time of inspection.
Employee # 19, a counselor was hired April 15, 2015. HIV/AIDS and TB/STD training was to be completed within the first year of employment or by April 15, 2016. The facility failed to document that employee # 19 completed HIV/AIDS and TB/STD as of the time of inspection.
Employee # 20, a behavioral tech was hired July 16, 2013. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment or by July 16, 2015. The facility failed to document that employee # 20 completed TB/STD as of the time of inspection.
Employee # 21, a behavioral tech was hired June 25, 2014. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment or by June 25, 2016. The facility failed to document that employee # 21 completed HIV/AIDS and TB/STD as of the time of inspection.
Employee # 22, a behavioral tech was hired July 14, 2014. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment or by July 14, 2016. The facility failed to document that employee # 22 completed HIV/AIDS and TB/STD as of the time of inspection.
Employee # 23, a behavioral tech was hired June 25, 2014. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment or by June 25, 2016. The facility failed to document that employee # 23 completed HIV/AIDS and TB/STD as of the time of inspection.
Employee # 24, a behavioral tech was hired June 25, 2014. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment or by June 25, 2016. The facility failed to document that employee # 24 completed TB/STD as of the time of inspection.
Employee # 25, a behavioral tech was hired February 23, 2012. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment or by February 23, 2014. The facility failed to document that employee # 25 completed HIV/AIDS and TB/STD as of the time of inspection.
Employee # 26, a behavioral tech was hired July 18, 2010. HIV/AIDS and TB/STD training was to be completed within the first 2 years of employment or by July 18, 2012. The facility failed to document that employee # 26 completed HIV/AIDS and TB/STD as of the time of inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
5 of the 11 identified employees have already completed or brought in required documentation confirming HIV/AIDS and TB/STD training. The remaining individuals are scheduled to attend the next scheduled trainings by 2/28/17. All required staff trainings are the responsibility of the respective department supervisors/ directors. To prevent re-occurrence, required trainings will be monitored and tracked by the HR manager to ensure that all required trainings due for each member of staff are completed and report any trainings that would be due on a monthly basis to the appropriate department heads for follow-up with their personnel. Updates will be reported in monthly management meetings by HR to review status of the process and identify any variances. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
A physical plant inspection was conducted on November 4, 2016. The facility failed to keep fire retardant mattresses in good repairs in rooms # 111, 113, 115 and 215. Each mattress was discovered to be ripped/torn.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The mattresses identified during the inspection were replaced by 11/11/16. Moving forward all housekeeping staff will identify any such variances for follow up repair/replacement and report it to the Environmental Services Supervisor. Ongoing monitoring will be a daily process. Any variances identified will be addressed within 72 hours. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records on November 1-4, 2016, the facility failed to document informed and voluntary consents in client records, # 5, 6, 8, 9, 17, 19, 21, 23, 24, 25, 26 and 28.
Client #5 was admitted on October 28, 2016 and still active at the time of the inspection. An informed and voluntary consent was completed for a government agency on October 28, 2016, but failed to include a purpose of disclosure.
Client #6 was admitted on October 26, 2016 and discharge on October 27, 2016. An informed and voluntary consent was completed for a government agency on October 21, 2016, but failed to include a purpose of disclosure.
Client #8 was admitted on August 17, 2016 and discharge on August 23, 2016. An Informed and voluntary consent to release was completed on August 17, 2016. The facility checked the following agency/people on the consent to release; the client's emergency contact, funding source and primary care physician. The purpose for disclosure checked stated that it was "to provide third party payers with sufficient information." Additionally, provided client identifying information to a treatment provider on August 23, 2016 and August30, 2016. The facility failed to have a consent on file for that treatment provider.
Client #9 was admitted on May 13, 2016 and discharged on May 18, 2016. An informed and voluntary consent was completed on May 12, 2016. The facility checked the following agency/people on the consent to release; the client's emergency contact, funding source and primary care physician. The purpose for disclosure checked stated that it was "to provide third party payers with sufficient information."
Client #17 was admitted on July 21, 2016 and discharged on July 26, 2016. An informed and voluntary consent was completed on July 21, 2016 for the client's emergency contact, the facility failed to document the name of the person to whom disclosure is made.
Client #19 was admitted on May 4, 2016 and discharged on May 10, 2016. Informed and voluntary consents were completed on May 4, 2016 for a treatment provider, the client's emergency contact, funding source and a government agency, the facility failed to document the date of the client's signature.
Client #21 was admitted on October 27, 2016 and still active at the time of the inspection. An informed and voluntary consent was completed on October 27, 2016 for a funding source, the facility failed to document the purpose of disclosure. Additionally, a consent to release also dated October 27, 2016 for the client's emergency contact, the facility failed to document the name of the person to whom disclosure was made.
Client #23 was admitted on October 9, 2016 and discharge on November 1, 2016. The facility provided client identifying information to a treatment provider on November 2, 2016 with no consent documented for this treatment provider.
Client #24 was admitted on September 12, 2016 and still active at the time of the inspection. An informed and voluntary consent was completed on September 29, 2016 for a family member, the facility failed to document the purpose of disclosure. Additionally, the facility provided client identifying information to a treatment provider on September 22, 2016 with no consent documented for this treatment provider.
Client #25 was admitted on August 30, 2016 and discharge on October 6, 2016. An informed and voluntary consent was completed on September 7, 2016 for a family member, the facility failed to document the purpose of disclosure. Additionally, on October 6, 2016, a letter was sent out to "Whom it may concern."
Client #26 was admitted on April 25, 2016 and discharge on May 17, 2016. Informed and voluntary consents were completed on April 25, 2016 for the client's emergency contact and primary care physician, the facility failed to document on each consent form the name of the person to whom disclosure is made.
Client #28 was admitted on June 3, 2016 and discharge on July 11, 2016. An informed and voluntary consent was completed on April 25, 2016 for the client's emergency contact, the facility failed to document the name of the person to whom disclosure is made.
The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clients #21 and #24 who were active at the time of the inspection discharged and are no longer active for follow up. Retraining on proper voluntary consent documentation will occur for all staff responsible for consent form documentation by each department's respective supervisors to include clinical, nursing and admissions departments. To prevent re-occurrence ongoing monitoring will occur for a period of no less than 3 months or until supervisory staff have deemed that monitoring is no longer required. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on the review of patient records and an interview with facility staff on November November 3, 2016, the physician failed to adhere to the dosing protocol listed on the medication in patient record #24.
Per the manufacturer's dosing and administration instructions "Suboxone sublingual film must be administered whole". Prescriptions need to be for the manufactured quantities of 12 mg/3 mg, 8 mg/2 mg, 4 mg/1 mg or 2 mg/.5 mg doses.
Patient # 24 was admitted into Suboxone treatment on September 12, 2016 and still active at the time of the inspection. The physician prescribed films of Suboxone on September 21, 2016 and September 22, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 12/21/16, all Suboxone strips are now provided by our contracted pharmacy in 4mg and 8mg strips and are not cut, and physician orders are consistent with 4mg or 8mg dosages. Monitoring for adherence will occur for a period not less than 3 months by nursing management and any variances reported monthly in dashboard meetings. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of detox patient records on November 1-2, 2016, the facility failed to notify the transferring facility the date of the initial dose in patient record #5.
Client #5 was transferred to the facility on November 2, 2016 and still active at the time of the inspection.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Retraining on proper transfer documentation procedure will occur for specific staff responsible for the identified variance. Retraining will occur in documented supervision by their respective supervisors. Ongoing monitoring will occur during scheduled supervision for a period of no less than 3 months or until supervisory staff have deemed that monitoring is no longer required. Any variances to be reported to management team during monthly dashboard meetings. |