INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 8-9, 2023, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Kirkbride Center was found not to be 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 August 9. 2023, the facility failed to ensure the grounds were clean, safe and sanitary. Client belongings were observed to be in piles, bags and suitcases on the floor in the search room.
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Plan of Correction
Environmental cleaning staff are responsible for overall cleanliness and have cleaned the search room and will do so daily. A storage rack for temporary placement of items off the floor has also been ordered for the room. Tech Supervisors are responsible for monitoring and maintaining staff adherence to protocols in the search room and will monitor for cleanliness 2x during each of their shifts as well as ensure that belongings are appropriately stored both during and upon completion of the search process. |
705.5 (a) (2) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(2) A pillow and bedding appropriate for the temperature in the facility.
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Observations
Based on client interviews conducted on August 8,2023, along with a physical plant inspection conducted on August 9, 2023, the facility failed to ensure that in each bedroom, each resident had a pillow and bedding appropriate for the temperature in the facility. Three of five clients interviewed reported not having a pillow or not having linens, upon admission to the facility.
In unit N2, room # 201 and room # 210 each had a bed missing a pillow and a blanket. There were no extra pillows observed in the unit's linen closet nor in the basement storage area.
In unit CS2 room # 264 had a bed missing a pillow. There were no extra pillows observed in the linen closet utilized for this unit, nor in the basement storage area.
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Plan of Correction
Environmental cleaning staff are responsible for providing fresh linen/pillows in freshly cleaned patient rooms upon turnover. Tech Supervisors will be responsible for monitoring compliance on each unit during their respective shift and maintaining an adequate number of linen/pillows in each unit's storage location and will keep extra pillows in the Supervisor's office in case of emergencies to which the Shift Director will have access if/when needed. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a review of the Pest Sighting Log and client interviews conducted on August 8, 2023, the facility failed to be free of rodent infestation. The Pest Sighting Log documented the sighting of mice in the facility twenty times between May 2023 to the date of the review of the documentation on August 8, 2023. One of five clients interviewed reported seeing a mouse in her bedroom on two separate occasions in August.
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Plan of Correction
Our current process of 2x/wk visits by our pest control vendor will be increased to 3x/wk. Additionally, unit techs will continue to inform patients during community meetings that maintaining any food-related items in their rooms is not permitted for the very reasons cited, and that random rounding will occur each shift to enforce this, and any foodstuffs found will be removed in an attempt to aid in minimizing attraction of pests onto units and patient rooms. |