INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and Methadone and Buprenorphine monitoring conducted on December 2, 2019 through December 4, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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(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
The facility failed to provide documentation of an individual training plan for the current training year, identified as July 1, 2019 to June 30, 2020, in 11 of 36 employee records reviewed.
Employee # 26 was hired as a behavioral health tech on September 23, 2019. There was no documentation of an individual training plan for the current year in the employee file.
Employee # 27 was hired as a behavioral health tech on September 23, 2019. There was no documentation of an individual training plan for the current year in the employee file.
Employee # 28 was hired as a behavioral health tech on September 23, 2019. There was no documentation of an individual training plan for the current year in the employee file.
Employee # 29 was hired as a behavioral health tech on September 23, 2019. There was no documentation of an individual training plan for the current year in the employee file.
Employee # 30 was hired as a behavioral health tech on September 23, 2019. There was no documentation of an individual training plan for the current year in the employee file.
Employee # 31 was hired as a behavioral health tech on September 23, 2019. There was no documentation of an individual training plan for the current year in the employee file.
Employee # 32 was hired as a nurse on October 28, 2019. There was no documentation of an individual training plan for the current year in the employee file.
Employee # 33 was hired as a nurse on September 23, 2019. There was no documentation of an individual training plan for the current year in the employee file.
Employee # 34 was hired as a nurse on October 28, 2019. There was no documentation of an individual training plan for the current year in the employee file.
Employee # 35 was hired as a nurse on October 28, 2019. There was no documentation of an individual training plan for the current year in the employee file.
Employee # 36 was hired as the assistant director of nursing on October 28, 2019. There was no documentation of an individual training plan for the current year in the employee file.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on Surveyors feedback, training plan completion times have been updated so that they will now be completed within 30 days of hire and staff have been notified of the change, effective starting 1/1/2020. HR Manager (or designee) will be responsible for monitoring and tracking of training plan completion dates and communicate upcoming training plan due dates to the appropriate department heads for completion within the required time-frame. Any variances identified will be brought to the attention of the relevant manager/director for remediation with those staff responsible for training plan completion and findings will be discussed monthly in rehab dashboard meeting. |
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
The facility failed to ensure that all bathrooms were maintained in a functional manner at all times. Additionally, the facility failed to ensure that the hot and cold water was under pressure and the hot water temperature did not exceed 120 degrees Fahrenheit. The following issues were observed during the physical plant inspection conducted on December 4, 2019 at approximately 10:30 am:
-The sink in room 317 was inoperable. There was no hot or cold water pressure.
-Hot water temperatures were recorded at 139 degrees in rooms 107, 117, 203, 207, and 214.
-The exhaust fans in the detox unit bathrooms were all inoperable.
-The toilets in rooms 5 and 207 were inoperable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Three of the areas cited during the survey (i.e., sink, water temp and toilets) were addressed by engineering staff at the time of the inspection, and the exhaust fans by 12/9. All maintenance issues identified are called into the Engineering's Facility Request line and are dispatched/addressed by the Office Manager in order of priority in coordination with the Property Manager. Maintenance issues called in will be reviewed daily by the Office Manager who will monitor and track any identified problems to ensure their resolution within a timely manner. Additionally, monthly EOC rounds will be used to ensure completion of any previously identified areas of concern and report on any identifiable areas that still need to be addressed. Any additional findings will be shared with the Property Manager for resolution, and all findings will be reported during monthly Safety Meeting. |
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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in 1 of 15 client records reviewed.
Client # 1 was admitted to the detoxification level of care on November 26, 2019 and was still active at the time of the inspection. There was documentation of a last dose verification sent to another provider on December 1, 2019; however, there was no consent to release information on file prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Admission and Detox Managers have conducted a re-training of staff regarding appropriate consent form documentation with all fields to be fully and accurately completed prior to any release of information. Compliance Analyst will conduct random monthly audits of patient records for a period of 3 months to ensure that consent form documentation and any release of information is being adhered to, per regulations. Any variances identified will be brought to the attention of the Admissions and Detox Managers immediately for remediation, and findings discussed monthly in rehab dashboard meeting. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to document the name of the person, agency or organization to whom the disclosure was to be made to on a consent form in 3 of 15 client records.
Client # 1 was admitted to the detoxification level of care on November 26, 2019 and was still active at the time of the inspection. There was a consent to release information form signed and dated by the client on November 26, 2019; however, the consent form did not include the specific name of the person, agency or organization.
Client # 5 was admitted to the detoxification level of care on August 30, 2019 and was discharged on September 4, 2019. There was a consent to release information form to "insurance" signed and dated by the client on August 30, 2019; however, the consent form did not include the specific name of the insurance company.
Client # 8 was admitted to the inpatient non-hospital level of care on September 4, 2019 and was active at the time of the inspection. There was a consent to release information form to "insurance" signed and dated by the client on August 30, 2019; however, the consent form did not include the specific name of the insurance company.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Admission Manager has conducted a re-training of staff regarding appropriate consent form documentation with all fields to be fully and accurately completed. Compliance Analyst will conduct random monthly audits of patient records for a period of 3 months to ensure that consent form documentation is being adhered to, per regulations. Any variances identified will be brought to the attention of the Admissions Manager immediately for remediation and findings discussed monthly in rehab dashboard meeting. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to include the specific information that was to be disclosed on a consent to release information form in 3 of 15 client records.
Client # 1 was admitted to the detoxification level of care on November 26, 2019 and was still active at the time of the inspection. There was a consent to release information form signed and dated by the client on November 26, 2019; however, the consent form did not include the specific information to be disclosed.
Client # 7 was admitted to the detoxification level of care on November 7, 2019 and was discharged on November 12, 2019. There was a consent to release information form to a funding source signed and dated by the client on November 7, 2019; however, the consent form listed one of the items to be disclosed as "other" with no specification of what would be released.
Client # 10 was admitted to the inpatient non-hospital level of care on November 12, 2019 was active at the time of the inspection. There was a consent to release information form to a funding source signed and dated by the client on November 7, 2019; however, the consent form listed one of the items to be disclosed as "other" with no specification of what would be released.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Admission Manager has conducted a re-training of staff regarding appropriate consent form documentation with all fields to be fully and accurately completed. Compliance Analyst will conduct random monthly audits of patient records for a period of 3 months to ensure that consent form documentation is being adhered to, per regulations. Any variances identified will be brought to the attention of the Admissions Manager immediately for remediation and findings discussed monthly in rehab dashboard meeting. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the individual's identity, including name, address and date of birth, prior to the administration of a narcotic agent in one of nine applicable patient records.
Patient # 7 was admitted to the detoxification level of care on November 7, 2019 and was discharged on November 12, 2019.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Admissions Manager is responsible for ensuring our existing ID verification process is initiated with patients admitted to our NTP. Compliance Analyst will conduct random monthly audits of patient records for a period of 3 months to ensure compliance in those patient records prior to administration of a narcotic agent, per regulations. Any variances identified will be brought to the attention of the Admissions Manager immediately for remediation and findings discussed monthly in rehab dashboard meeting. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to complete a random monthly urinalysis screening in one of nine client records.
Patient # 8 was admitted to the inpatient non-hospital level of care on September 4, 2019 and was active at the time of the inspection. There were no documented drug screen urinalysis for the month of September 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Shift Director is responsible for identifying and ensuring UDS completion for those clients requiring 30-day UDS's as per stated regulation. To ensure compliance, the Shift Director will coordinate monthly with the BHTs on each unit who will check that all specimens for those identified individuals have been collected. The Shift Director will cross-reference those individuals' completed UDS's with the census sheet to ensure that all names listed for UDS collection have been collected. Any variances identified will be followed up within 24 hours to ensure that a UDS is obtained and any outstanding variances reported monthly during rehab dashboard meeting |