INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4-7, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center, was found to be not 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(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 administrative reveiw and a review of employee files conducted on December 4, 2017, the facility failed to develop a current training plan for 48 employees.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
HR Director or designee is monitoring completion of all Individual Training Plans to ensure ongoing compliance, and ensure that the missing 48 individual training plans are completed. Additionally, the process for completion of the individual training plans for the nursing department is being revised to ensure adequate supervision and time to complete the necessary Performance Evaluations as well as the Individualized Training Plans. All managers/supervisors have already received a copy of the manual reviewing these processes and ongoing training will be provided to newly assigned managers/supervisors and anyone that needs a refresher course. |
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 administrative review and a review of employee files conducted on December 4, 2017, the facility failed to ensure that four staff members received the required communicable disease trainings within the specified timeframe.
Employee #16 was hired as a counselor on 10/17/2016. The TB/STD training was to be completed by 10/17/2017 but was not documented at the time of the inspection.
Employee #17 was hired as an administrative coordinator on 10/14/2015. The HIV/Aids and TB/STD trainings were to be completed by 10/14/2017 but were not documented at the time of the inspection.
Employee #18 was hired as a behavioral tech on 10/16/2013. The HIV/Aids and TB/STD trainings were to be completed by 10/16/2015 but were not documented at the time of the inspection.
Employee #19 was hired as a behavioral tech on 11/12/12014. The HIV/Aids and TB/STD trainings were to be completed by 11/12/2016 but were not documented at the time of the inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The HR Director has contacted the four (4) individuals that were out of compliance (#16, 17, 18, 19) with the mandatory training sessions and has scheduled them for the next training session on 1/12/18. Failure to complete the identified trainings on the given date will result in their removal from the schedule. The HR Director will monitor ongoing monthly compliance with mandatory training sessions and due dates for all employees. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection conducted on December 6, 2017, the facility failed to provide ventilation in all bathrooms.
The facility's central mechanical ventilation unit was not providing adequate ventilation to bathrooms throughout the facility.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Engineering staff immediately began cleaning the units' bathroom vents during the inspection to address ventilation issues identified by the surveyor and were completed 12/22/17. Both exhaust fans are currently in operation and running, engineering having replaced a broken fan belt on one of the two central exhaust fans during the survey on 12/7/17. Routine maintenance checks of ventilation system to be conducted monthly during EOC rounds by engineering staff to prevent re-occurrence and is under the oversight of the Property Manager. |
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
Twenty client records were reviewed on December 4-7, 2017. The facility failed to document a valid consent to release information form in client records #12 & 15-17. The consent to release information template, to a treatment provider, could only be revoked in writing.
Client #12 was admitted on 4/28/17 and was discharged on 10/16/17. The consent to release information to a treatment provider was signed by the client but not dated; the witness signature was dated 4/27/17.
Client #15 was admitted on 9/15/17 and was an active client at the time of the licensing inspection. The consent to release information to a treatment provider was dated 9/18/17.
Client #16 was admitted on 8/23/17 and was an active client at the time of the licensing inspection. The consent to release information to a treatment provider was dated 8/30/17.
Client #17 was admitted on 7/7/17 and was discharged on 9/13/17. The consent to release information to a treatment provider was dated 7/10/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The consent to release form cited in records (#12, 15-17) was revised by the Compliance Director to contain the correct revocation language identical to our other release forms and reviewed with the surveyor at time of inspection and approved for use by management same day (12/7/17). Edits to any official document to receive management team approval prior to implementation to prevent future re-occurrence and is under the oversight of the Compliance Director. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Twenty client records were reviewed on December 4-7, 2017, ten of which were methadone clients. The facility failed to have the narcotic treatment physician co-sign the history and physical in five client records.
Client #1 was admitted on 12/1/17 and was an active client at the time of the licensing inspection. The history and physical was completed by a Certified Registered Nurse Practitioner on 12/1/17 with no documented physician ' s counter-signature.
Client #9 was admitted on 8/13/17 and was discharged from detox on 8/16/17. A complete physical examination was completed by a Certified Registered Nurse Practitioner on 8/14/17 with no documented physician ' s counter-signature.
Client #10 was admitted on 10/27/17 and was discharged from detox on 10/30/17. A complete physical examination was completed by a Certified Registered Nurse Practitioner on 10/27/17 with no documented physician ' s counter-signature.
Client #15 was admitted on 9/15/17 and was an active client at the time of the licensing inspection. The history and physical was completed by a Certified Registered Nurse Practitioner on 9/15/17 with no documented physician ' s counter-signature.
Client #16 was admitted on 8/23/17 and was an active client at the time of the licensing inspection. The history and physical was completed by a Certified Registered Nurse Practitioner on 8/23/17 with no documented physician ' s counter-signature.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The physicians met with the ED to review the identified deficiencies in the 5 client records cited (#1, 9, 10, 15, 16) and review the regulation requiring a countersignature by the physician for the CRNP. The Medical Director is also revising the Physician's Documentation of Opiate Addiction form that is signed by the physician to help improve regulatory requirements. Oversight and monitoring of adherence to the regulation will be conducted by the Compliance Director or designee. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Twenty client records were reviewed on December 4-7, 2017, ten of which were methadone clients. The facility failed to document a valid consent to treatment with methadone in one client record.
Client #4 was admitted on 9/5/17 and was discharged from detox on 9/10/17. The informed consent to methadone treatment was signed by the client but the signature was not dated.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The physicians met with the ED to review the identified deficiency in the 1 client record cited (#4) where the patient had not dated their signature on the informed consent for methadone treatment and were educated about ensuring completion of documented signatures/dates by all parties. Oversight and monitoring of adherence to the regulation will occur under the Compliance Director or designee. |
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
Twenty client records were reviewed on December 4-7, 2017, ten of which were methadone clients; the facility failed to update the treatment plan every 30 days in client record #16.
Client #16 was admitted on 8/23/17 and was an active client at the time of the licensing inspection. #16 received the first methadone dose on 8/30/16. The comprehensive treatment plan was dated 8/25/17; a treatment plan update was due by 9/25/17 but was not documented until 9/29/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The therapist responsible for chart #16 was given written counseling by the Clinical Director regarding treatment plan regulations and the appropriate timeline for treatment plan updates. The clinical team has also been re-educated by the Clinical Director around the regulations for treatment planning and treatment plan updates. Oversight and monitoring for treatment plan requirements will be conducted by the appropriate Clinical Managers/ Supervisors responsible for clinical supervision. |