INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 7, 2023 through September 8, 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of personnel records, the facility failed to follow their own policy regarding collecting feedback on completed trainings.
The facility policy and procedure manual states that a training feedback form will be completed for each internal training. In every personnel record reviewed, there were internal annual trainings documented; however, there were no training feedback forms completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our new HR Director is responsible for ensuring that training requirements are completed and documented, including developing and implementing a comprehensive staff development program and retaining documentation indicating that all components are completed. HR Director will ensure that a training feedback form is developed and provided to all trainers, and that they are aware it is to be provided to all staff in attendance at staff trainings and collected at the end of the program from starting 11/1/23. The feedback forms will be maintained in the relevant employee training files. The HR Director will monitor completion of feedback forms in staff files for compliance and report any variances monthly to leadership in the monthly rehab dashboard. |
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, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in two of thirteen applicable personnel records reviewed.
Employee # 19 was hired as a counselor on August 29, 2022 and was due to have the TB/STD training no later than August 29, 2023; however, the TB/STD training was not completed at the time of the inspection.
Employee # 21 was hired as a counselor on May 23, 2022 and was due to have the HIV/AIDS training no later than May 23, 2023; however, the HIV/AIDS training was not completed at the time of the inspection.
This is a repeat citation from the November 30-December 1, 2022 licensing inspection and the April 13, 2023 through April 114, 2023 provisional license follow up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our new HR Director is responsible for ensuring that training requirements are completed and documented and will implement a process using the HRIS system to track compliance with training requirements. Reports will be generated monthly to identify staff who have outstanding training requirements and, beginning three months prior to due date for training requirements the HR Director will notify employees and their managers via email monthly. The employees will be informed that the HR Director will schedule mandatory internal trainings for the employees and will assist with scheduling non-mandatory external trainings as needed. Employee #19 completed the TB/STD training on September 9, 2023. Employee #21 is scheduled to complete the HIV/AIDS training on October 14, 2023. Moving forward, employees who are non-compliant will be suspended until they complete the required training. The HR Director will report monthly to leadership regarding ongoing compliance with training requirements. If the rate of compliance is less than 100%, additional strategies will be implemented to ensure the necessary rate of compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2022 through June 30, 2023 training year in five of ten applicable personnel records reviewed.
Employee # 12 was hired as a counselor on June 19, 2022. The personnel record documented 0 hours of training received during the training year reviewed.
Employee # 18 was hired as a counselor on April 18, 2022. The personnel record documented 19 hours of training received during the training year reviewed.
Employee # 23 was hired as a counselor on September 8, 2020. The personnel record documented 14.5 hours of training received during the training year reviewed.
Employee # 24 was hired as a counselor on January 27, 2020. The personnel record documented 19 hours of training received during the training year reviewed.
Employee # 25 was hired as a counselor on December 21, 2010. The personnel record documented 22.5 hours of training received during the training year reviewed.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
Our new HR Director is responsible for ensuring that training requirements are completed and documented. HR Director will ensure that all counselors, Clinical Supervisors and Program Directors are aware of their annual training requirements and their progress toward same by sending them emails annually re: the requirements, and sending reminder emails to counselors every quarter documenting their progress toward training requirements as their annual due dates for demonstrating full compliance approach. HR Director will ensure that the emails instruct employees how to provide documentation of attending external trainings to the HR Director. It should be noted that while documentation was not present at the time of the survey evidencing a total of 25 clock hours for the 5 employees cited (#12, 18, 23, 24 and 25), upon further review it was identified that, in addition to their internal 12.5 hours annual trainings, Employee # 12 had completed 32 external training hours meeting the requirement; Employee #23 completed 22 external training hours meeting the requirement; and Employee #25 completed 13 external training hours meeting the requirement. HR Director will also send reports showing progress toward training requirements to Supervisors to enable them to monitor compliance by Counselors. |
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 September 7, 2023 between 9:30 AM and 12:30 PM, 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 the pool area group room with the door open that could be seen and heard from outside the counseling room.
This is a repeat citation from the April 13, 2023 through April 14, 2023 provisional license follow up inspection.
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 the pool room area was counseled about this by the Program Director who has also communicated and reinforced this regulation with all clinical staff. Security staff will conduct rounds during group times to monitor compliance and will report any variances real-time to Clinical Managers for follow-up and remediation as needed. |
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 September 7, 2023, between 9:30 AM and 12:30 PM, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
-The bathroom in room 286 had a clogged sink.
-The bathroom in room 402 had the presence of soap scum.
-The bathroom in room 407 had the appearance of mold/mildew.
-The bathroom in room 409 had the appearance mold/mildew and rust.
-The bathroom in room 516 had the appearance of mold/mildew and dirt.
This is a repeat citation from the December 1, 2021 through December 3, 2021 and the November 30, 2022 through December 1, 2022 annual licensing renewal inspection inspections, as well as the April 13, 2023 through April 14, 2023 provisional license follow up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All areas cited during the survey in rooms 286, 402, 407, 409 and 516 were addressed same day by environmental services or engineering staff. The Environmental Service Managers are responsible for ensuring their staff provide daily cleaning on patient units which is an ongoing daily process - and while cleaning was conducted of the areas observed in rooms 402, 407, 409 and 516, upon closer inspection the presence of mold/mildew was not confirmed. The Property Manager is responsible for any work orders submitted for the engineering department and this is also an ongoing daily process. Per his report the clogged sink in room 286 had not been reported yet as a work order to his department for resolution and it is presumed that the clog was very recent in origin. Monitoring of completion is conducted by the EOC Coordinator, and any variances identified are 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. |
705.8 (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 9:30 AM and 2:30 PM, the facility failed to ensure that all heaters were permanently mounted or installed.
There was a space heater located on 3N behind the nurse ' s station and a space heater was in the administrative office on the first floor.
This is a repeat citation from the November 30, 2022 through December 1, 2022 annual licensing renewal inspection and the April 13, 2023 through April 14, 2023 provisional license follow-up inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The portable space heaters were removed from the identified areas and the Department Managers have followed-up with the identified staff for remediation and education of the regulation with instructions to comply or face further action. The Property Manager will also be responsible for assessing those areas identified for any heating/cooling concerns and, if indicated and feasible, explore possible mounting of permanent heating units. Department Managers will be responsible for conducting periodic rounds to monitor for these items in staff areas 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 September 7, 2023, between 9:30 AM and 12:30 PM, the facility failed to limit smoking to designated smoking areas.
There were cigarette butts and ashes in several areas of the facility, including the exterior walkway from the kitchen to the main building and in bathrooms located in rooms 361, 365, 506, 33, 317, 319, 264, 281, and 314.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Property Manager has put designated smoking areas in place outside the buildings with signage informing individuals where it is permissible to smoke. Any contraband-related smoking materials (i.e., matches, lighters) will be confiscated by staff if/when discovered. Staff will continue to enforce non-smoking rules inside buildings when discovered and take appropriate action to report this behavior to clinical management for timely review and intervention up to and including possible administrative discharge for failure to follow program rules. The Environmental Service Managers are responsible for ensuring their staff provide daily cleaning on patient units which is an ongoing daily process. If, during their cleaning they see evidence of any smoking they will report it timely to the unit staff for review with clinical management. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguisher upon employment in three of seven applicable personnel records reviewed.
Employee # 7 was hired as a counselor on March 8, 2023. The personnel record documented that the fire extinguisher training was not completed until April 17, 2023.
Employee # 9 was hired as a counselor on December 5, 2022. The personnel record documented that the fire extinguisher training was not completed until January 23, 2023.
Employee # 10 was hired as a counselor on December 5, 2022. The personnel record documented that the fire extinguisher training was not completed until January 23, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our new HR Director is responsible for ensuring that training requirements are completed and documented. The HR Director will ensure that all newly hired staff participate in the organization's New Employee Orientation program, which includes training on the use of fire extinguishers, prior to being able to commence providing services at Kirkbride. This process was implemented by Kirkbride's new HR Director and Executive Director in Spring of 2023 and applied to 2 recently hired Counselors (hire dates 7/15/23 & 8/21/23), whose training on the use of fire extinguishers was appropriately provided on their first day of employment and documented in their files. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in three of seven applicable personnel records reviewed.
Employee # 7 was hired as a counselor on March 8, 2023. The personnel record documented that the training to perform assigned tasks during emergencies was not completed until April 17, 2023.
Employee # 9 was hired as a counselor on December 5, 2022. The personnel record documented that the training to perform assigned tasks during emergencies was not completed until January 23, 2023.
Employee # 10 was hired as a counselor on December 5, 2022. The personnel record documented that the training to perform assigned tasks during emergencies was not completed until January 23, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our new HR Director is responsible for ensuring that training requirements are completed and documented. The HR Director will ensure that all newly hired staff participate in the organization's New Employee Orientation program, which includes training on assigned tasks during emergencies, prior to being able to commence providing services at Kirkbride, and that the New Employee Orientation is documented in each employee's individual file. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's January 2023 through August 2023 fire drill logs, the facility failed to ensure that all written fire drill logs included the exit route used and the number of persons in the facility at the time of the drill.
Every monthly fire drill log conducted during the reviewed period did not include which exit route was used. Additionally, the August 2023 fire drill log did not include the number of persons in the facility at the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Security Manager is responsible for Fire Drill/Alarm reports. Upon review the logs did contain the appropriate prompts to capture the items cited (i.e., number of persons in the facility at the time of the drill, as well as the exit used). However, at least in one instance a # was not indicated in the appropriate field, and it was also noted upon review that "exits used" are not on the main drill report but exist on separate evaluation forms by unit that supplement the main report. Moving forward, the Security Manager will ensure that all supplemental forms are collected from the units and maintained with the main drill report, and that they are submitted for review during annual inspections along with the main drill report. The Security Manager will verify compliance during quarterly reviews. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee, in seven of sixteen applicable personnel records.
Employee # 2 was hired as a clinical supervisor on March 13, 2017. There was no current annual performance evaluation documented at the time of the inspection.
Employee # 12 was hired as a counselor on June 19, 2022. There was no current annual performance evaluation documented at the time of the inspection.
Employee # 16 was hired as a counselor on January 31, 2022. There was no current annual performance evaluation documented at the time of the inspection.
Employee # 18 was hired as a counselor on April 18, 2022. There was no current annual performance evaluation documented at the time of the inspection.
Employee # 19 was hired as a counselor on August 29, 2022. There was no current annual performance evaluation documented at the time of the inspection.
Employee # 21 was hired as a counselor on May 23, 2022. There was no current annual performance evaluation documented at the time of the inspection.
Employee # 25 was hired as a counselor on December 21, 2010. There was no current annual performance evaluation documented at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Our new HR Director is responsible for ensuring that individual staff performance evaluations are completed and documented appropriately and has obtained and filed the completed managers' annual evaluations for the 7 staff identified (#2, 12, 16, 18, 19, 21, 25). The HR Director will ensure compliance by implementing a new electronic method of tracking completion of annual performance evaluations. The HR Director will alert Managers via email at least two months in advance of evaluation due dates and provide at least one email a month in advance of the due date. The HR Director along with facility leadership will be responsible for holding managers accountable for timely completion. Managers will be made aware that failure to complete performance evaluations timely may result in discipline. |
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 the physical plant inspection, conducted on September 7, 2023, between 9:30 AM and 12:30 PM, the facility failed to secure hard copy client records within locked storage containers as there was client-related documentation and client records found unsecured in rooms 121, 123, 523, 321, 323 and 750.
This is a repeat citation from the April 13, 2023 through April 14, 2023 provisional license follow-up inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff members are responsible for maintaining confidentiality of client records in their offices. Clinical Managers have met with those staff members whose offices were cited and provided re-education regarding confidentiality of client records and maintaining them within locked storage containers. Leadership is exploring an electronic medical record system to be in place in 2024 which will help alleviate such issues in the future. In the interim, we are purchasing locked storage containers for offices and random monthly checks will occur by all managers to ensure that staff are in compliance with the regulation and will address any variances found with those staff members when needed. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician reviewed the dosage levels at least twice a year, with each review occurring at least 2 months apart, in three of five applicable patient records reviewed.
Patient #2 was admitted to the outpatient maintenance activity on August 18, 2022 and was still active at the time of inspection. There was no documentation, in the record, of a dosage level review by a narcotic treatment physician.
Patient #4 was admitted to the outpatient maintenance activity on June 10, 2022 and was still active at the time of inspection. There was no documentation, in the record, of a dosage level review by a narcotic treatment physician.
Patient #7 was admitted to the outpatient maintenance activity on January 31, 2022 and was still active at the time of inspection. There was no documentation, in the record, of a dosage level review by a narcotic treatment physician.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The dosage levels for client #'s 2, 4 and 7 were reviewed and documented by the NTP. Moving forward the Compliance analyst will review patient records to ensure that each patient record contains the necessary reviews. If there is no dosage level review after 6 months, the Compliance analyst will inform the Medical Director, who will address the issue with the NTP. If, at the 10-month mark there is zero or one dosage level reviews, the Compliance analyst will inform the Medical Director, who will address the issue with the NTP. Validation audits will occur periodically by the Compliance analyst to ensure compliance and any variances will be reported to leadership for review. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to ensure an annual evaluation of the patient's status was completed by the patient ' s counselor and was reviewed, dated, and signed by the medical director in five of five applicable patient records reviewed.
Patient #2 was admitted to the outpatient maintenance activity on August 18, 2022 and was still active at the time of inspection. The annual evaluation of the patient's status was not completed at the time of inspection.
Patient #3 was admitted to the outpatient maintenance activity on March 4, 2022 and was still active at the time of inspection. The annual evaluation of the patient's status was not completed at the time of inspection.
Patient #4 was admitted to the outpatient maintenance activity on June 10, 2022 and was still active at the time of inspection. The annual evaluation of the patient's status was not completed at the time of inspection.
Patient #5 was admitted to the outpatient maintenance activity on June 8, 2022 and was still active at the time of inspection. The annual evaluation of the patient's status was not completed at the time of inspection.
Patient #7 was admitted to the outpatient maintenance activity on January 31, 2022 and was still active at the time of inspection. The annual evaluation of the patient's status was not completed at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The annual clinical evaluations for client #'s 2, 3, 4, 5 and 7 were completed by the counselor and reviewed, dated and signed by the Medical Director. Moving forward the clinic Compliance Analyst will be responsible for monitoring appropriate timeframes for the annual evaluation by the counselor and for notifying the counselor of any upcoming annual evaluations that are due for completion and for review and sign-off by the Medical Director. Validation audits will occur periodically by the Compliance Analyst to ensure compliance and any variances will be reported to leadership for review. |
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 a physical plant inspection and administrative review, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for not 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, December 3, 2021, and December 1, 2022 annual licensing inspections, as well as the April 14, 2023 provisional license follow-up inspection. Not maintaining each bathroom in a functional, clean, and sanitary manner at all times was again found to be a deficiency in the September 7, 2023 through September 9, 2023 annual licensing inspection.
Plans of correction not ensuring all staff receive a minimum of 6 hours of HIV/AIDS training and/or at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe were submitted and approved by the department for the December 1, 2022 annual licensing renewal inspection and the April 14, 2023 provisional license follow-up inspection. Not ensuring all staff are trained for the HIV/AIDS training and the TB/STD and other related topics training was again found to be a deficiency in the September 7, 2023 through September 9, 2023 annual licensing inspection.
Plans of correction ensuring all heaters were permanently mounted or installed were submitted an approved by the Department for the December 1, 2022 annual licensing renewal inspection and the April 14, 2023 provisional license follow-up inspection. Not ensuringall heaters were permanently mounted and installed was again found to be a deficiency in the September 7, 2023 through September 9, 2023 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Items related to cleanliness, functionality and sanitation are areas that require continuous monitoring and resolution and can and do occur daily. Since our last survey in April, we have implemented increased oversight and monitoring on plant-related environmental issues. The new Property and Environmental Services Mgrs., and senior leadership [President/CEO, Board of Directors] will continue to be notified daily by our Environment of Care (EOC) Coordinator of any areas that may require additional support and remediation from the engineering department, environmental services group and/or outside contracting services.
The Property Office Manager will also continue to 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 of Directors).
As for monitoring of required trainings (HIV/AIDs and TB/STD) we have recently undergone changes in leadership within our HR department with a new HR Manager and team who have been working to improve our tracking, monitoring, reporting and enforcement of required trainings by staff. Ongoing reporting of compliance to leadership [President/CEO, Board Directors] will also occur monthly for continuing oversight. |