INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on September 9, 2025 through September 12, 2025 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(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, the facility failed to develop a written individual training plan for each employee, with input from both the employee and the supervisor, in eleven of twenty-one applicable personnel records reviewed.Employee # 7 was hired as a counselor on September 16, 2024. There was no individual training plan documented in the personnel record at the time of the inspection.Employee # 8 was hired as a counselor on August 21, 2023. There was no individual training plan documented in the personnel record at the time of the inspection.Employee # 9 was hired as a counselor on June 17, 2024. There was no individual training plan documented in the personnel record at the time of the inspection.Employee # 12 was hired as a counselor on October 9, 2023. There was no individual training plan documented in the personnel record at the time of the inspection.Employee # 13 was hired as a counselor on June 19, 2022. There was no individual training plan documented in the personnel record at the time of the inspection.Employee # 14 was hired as a counselor on May 28, 2024. There was no individual training plan documented in the personnel record at the time of the inspection.Employee # 15 was hired as a counselor on January 2, 2024. There was no individual training plan documented in the personnel record at the time of the inspection.Employee # 17 was hired as a counselor on October 23, 2023. There was no individual training plan documented in the personnel record at the time of the inspection.Employee # 18 was hired as a counselor on July 19, 2005. There was no individual training plan documented in the personnel record at the time of the inspection.Employee # 19 was hired as a counselor on October 17, 2022. There was no individual training plan documented in the personnel record at the time of the inspection.Employee # 20 was hired as a counselor on January 27, 2020. There was no individual training plan documented in the personnel record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) is responsible for ongoing monitoring of completed staff training plans by the required date. The HR Director has met with the Program Director for follow up and the clinical supervisors have completed the individualized training plans for staff #'s (7, 8, 9, 12, 13, 14, 15, 17, 18, 19 and 20) as of 10/3/25. Moving forward clinical managers/supervisor will document areas of improvement and advanced education/training for their staff on individual topics in their training plans and based on staff response to the supervisor's input they can add additional trainings and /or requests for additional support as needed. Input by both the counselor and supervisor will be evidenced by both their signatures on the document. The HR Director (or designee) will monitor quarterly for ongoing compliance and report any variances to the department head for resolution. For future awareness, once our new Human Resources Information System (HRIS) is in place the form will be electronic and weekly notifications will be sent out when the due date is pending, when it is here, and if/when it has passed. |
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of personnel records, the facility failed to ensure each annual, written individual training plan was based upon the employee's previous education, experience, current job functions, and performance in two of ten applicable personnel records reviewed. Employee # 4 was hired as a clinical supervisor on November 11, 2021. The individual training plan, completed on June 20, 2025, was identical to the training plan for employee # 5 and was not individualized based on the employee's previous education, experience, current job functions and job performance.Employee # 5 was hired as a clinical supervisor on June 1, 2022. The individual training plan, completed on June 30, 2025, was identical to employee # 4 and was not individualized based on the employee's previous education, experience, current job functions and job performance.This is a repeat citation from the August 27, 2024 through August 29, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director is responsible for completion of the clinical supervisor's annual, written individual training plans. As of 10/1/25 we have updated the documentation to remove the default language so that all staff will be required to individualize staff's training plans based on their employee's previous education, experience, current job function and job performance. Also, as of 10/3/25 both Employees #4 and #5 have had their training plans re-done using the new documentation evidencing their individualization. Following the rollout of the new Human Resources Information System (HRIS) this document will be electronic and notifications will be sent out weekly when the due date is pending, when due date is here, and if/when it has passed. Until that time, monitoring will be done manually by the HR designee on a monthly basis and any variances will be reported to the department head for follow-up and resolution. |
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 Requirements Facility Summary Report, the facility failed to ensure 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 timeframes in twenty-two of twenty-five applicable personnel records reviewed. Employee # 9 was hired as a counselor on June 17, 2024 and was due to have the TB/STD and HIV/AIDS trainings no later than June 17, 2025; however, the TB/STD training was completed on September 10, 2025 and the HIV/AIDS training was completed on September 11, 2025.Employee # 11 was hired as a counselor on February 26, 2024 and was due to have the TB/STD and HIV/AIDS trainings no later than February 26, 2025; however, the TB/STD training was completed on September 6, 2025 and the HIV/AIDS training was completed on September 9, 2025.Employee # 14 was hired as a counselor on May 28, 2024 and was due to have the TB/STD training no later than May 28, 2025; however, the training was completed on September 10, 2025. Employee # 15 was hired as a counselor on January 2, 2024 and was due to have the TB/STD and HIV/AIDS trainings no later than January 2, 2025; however, the TB/STD training was completed on September 8, 2025 and the HIV/AIDS training was completed on March 6, 2025.Employee # 16 was hired as a counselor on June 3, 2024 and was due to have the TB/STD training no later than June 3, 2025; however, the TB/STD training was completed on September 18, 2025. Employee # 22 was hired as a behavioral health technician on September 11, 2023 and was due to have the TB/STD training no later than September 11, 2025; however, the training was not completed at the time of the inspection.Employee # 23 was hired as a behavioral health technician on October 31, 2022 and was due to have the TB/STD and HIV/AIDS trainings no later than October 31, 2024; however, both trainings were not completed at the time of the inspection.Employee # 24 was hired as a behavioral health technician on July 15, 2023 and was due to have the TB/STD and HIV/AIDS trainings no later than July 15, 2025; however, both trainings were not completed at the time of the inspection.Employee # 25 was hired as a behavioral health technician on August 29, 2022 and was due to have the HIV/AIDS training no later than August 29, 2024; however, the training was not completed at the time of the inspection.Employee # 26 was hired as a behavioral health technician on June 27, 2022 and was due to have the TB/STD and HIV/AIDS trainings no later than June 27, 2024; however, both trainings were not completed at the time of the inspection.Employee # 27 was hired as a behavioral health technician on March 28, 2022 and was due to have the HIV/AIDS training no later March 28, 2024; however, the training was not completed at the time of the inspection.Employee # 28 was hired as a behavioral health technician on July 25, 2022 and was due to have the HIV/AIDS training no later July 25, 2024; however, the training was not completed at the time of the inspection.Employee # 29 was hired as a behavioral health technician on November 28, 2022 and was due to have the TB/STD and HIV/AIDS trainings no later than November 28, 2024; however, both trainings were not completed at the time of the inspection.Employee # 30 was hired as a behavioral health technician on May 22, 2023 and was due to have the TB/STD and HIV/AIDS trainings no later than May 22, 2025; however, both trainings were not completed at the time of the inspection.Employee # 31 was hired as a behavioral health technician on March 28, 2022 and was due to have the HIV/AIDS training no later March 28, 2024; however, the training was not completed at the time of the inspection.Employee # 32 was hired as a behavioral health technician on September 11, 2022 and was due to have the TB/STD and HIV/AIDS trainings no later than September 11, 2024; however, both trainings were not completed at the time of the inspection.Employee # 33 was hired as a behavioral health technician on June 27, 2022 and was due to have the TB/STD and HIV/AIDS trainings no later than June 27, 2024; however, both trainings were not completed at the time of the inspection.Employee # 34 was hired as a behavioral health technician on June 19, 2023 and was due to have the TB/STD and HIV/AIDS trainings no later than June 19, 2025; however, the TB/STD training was completed on September 5, 2025 and the HIV/AIDS training was not completed at the time of the inspection.Employee # 35 was hired as an admissions coordinator on July 25, 2022 and was due to have the TB/STD and HIV/AIDS trainings no later than July 25, 2024; however, both trainings were not completed at the time of the inspection.Employee # 36 was hired as an admissions coordinator on March 27, 2023 and was due to have the TB/STD training no later than March 27, 2025; however, the training was not completed at the time of the inspection.Employee # 37 was hired as an admissions coordinator on October 10, 2022 and was due to have the TB/STD and HIV/AIDS trainings no later than October 10, 2024; however, both trainings were not completed at the time of the inspection.Employee # 38 was hired as an admissions coordinator on March 13, 2023 and was due to have the TB/STD and HIV/AIDS trainings no later than March 13, 2025; however, both trainings were not completed at the time of the inspection.This is a repeat citation from the September 7, 2023 through September 8, 2023 and August 27, 2024 through August 29, 2024 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HR Director (or designee) is responsible for monitoring and ensuring staff completion of the required communicable disease trainings within the regulatory timeframes. Employees #23 and 34 are no longer employed and we have subsequently verified completion of the required trainings for Employee #'s: 9, 11, 14, 15, 16, 22, 26, 27, 28, 32, 33, 35 and 38. In order to ensure that we are meeting the required trainings for HIV/AIDS and TB/STD we have revised our orientation schedule for all new hires in order to include the requisite trainings for (HIV/AIDS and TB/STD) using the state-approved curriculums as part of their onboarding process. This will begin as of the next new-hire orientation starting the week of October 13th, 2025. The remaining employees (#'s: 24, 25, 29, 30, 36 and 37) who still need to complete either or both trainings will be required to either attend the upcoming orientation starting the week of October 13th or complete the required training(s) online (if available) by 10/31/25. Current staff who are non-compliant must complete the required trainings by 10/31/25 or will not be allowed to work. The HR Director (or designee) will monitor ongoing compliance with mandatory training sessions and due dates for all employees and review findings with department managers. Any variances will be reported monthly to management team for review in rehab dashboard meeting. |
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 12, 2025 between 10am and 12pm, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.At the time of the inspection, there was a group counseling session being conducted in group room # 239 and the door was open and clients were able to be seen and heard. 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. The therapist in room #239 was a new hire that same month and was subsequently counseled about ensuring privacy during counseling sessions by the Clinical Supervisor in response same day, 9/10/25. 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 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, conducted on September 12, 2025 between 10am and 12pm, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom. At the time of the inspection, the bathrooms within client room #s 305, 401, 403, 409, and 413 did not have any individual paper towels or a mechanical dryer installed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The environmental manager of the housekeeping staff is responsible for adherence to replace individual paper towels in all client rooms. Those rooms identified during the survey (#s 305, 401, 403, 409 and 413) were resupplied immediately by their staff during the inspection. For monitoring purposes and ensure compliance with the regulation, daily environmental checks by the engineering staff will include a random validation audit of the paper towel dispensers to ensure that they are supplied. Any variances will be reported by the Property Manager to the environmental manager for remediation with their staff. |
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 12, 2025 between 10am and 12pm, the facility failed to ensure smoking was limited only to designated smoking areas. At the time of the inspection, the bathroom in client room #520 had cigarette ashes in the toilet and on the toilet seat. Additionally, the bathrooms in client room #s 303, 315, 411, and 420 smelled strongly of cigarette smoke.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Property Manager is responsible for monitoring for any non-compliance with smoking in designated areas only. Those rooms identified (#s 303, 315, 411 and 420) were reported at the time of inspection to the unit's nursing staff for follow-up with the clinical team for intervention with the identified clients in those rooms. For ongoing monitoring with the regulation, the engineering staff will be responsible during their daily rounds to report any variances to the unit BHTs for follow up with the clinical team. Those clients identified as non-compliant will be met with by their respective therapists for behavioral interventions and performance improvement as needed. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of consent to release information forms were offered to the client in two of twenty-one client records reviewed. Client # 19 was admitted to the outpatient activity on January 31, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed by the client on May 27, 2025; however, there was no documentation indicating a copy of the release form was offered to the client. Client #20 was admitted to the outpatient activity on April 13, 2022 and was still active at the time of inspection. The release of information form to an emergency contact was signed by the client on May 21, 2025; however, there was no documentation indicating a copy of the release form was offered to the client.This is a repeat citation from the August 27, 2024 through August 29, 2024 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors are responsible for fully and accurately completing release of information forms including documenting that a copy of the consent to release information was offered to the client. The counselor responsible in these 2 cited cases in outpatient was met with by their Clinical Supervisor and re-educated regarding this regulation and the two clients (#19 and #20) were met with by the counselor to document that a copy was offered by 9/30/25. The Compliance Analyst will conduct random monthly validation audits to monitor adherence with this regulation and any variances identified will be brought to the attention of the Program Director and Clinical Supervisor for remediation, and findings discussed monthly in rehab dashboard meeting. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to ensure the documentation of the written acknowledgment by clients that they had been notified of their client rights in eighteen of eighteen applicable client records reviewed.Client # 1 was admitted to the detoxification activity on September 3, 2025 and was active at the time of inspection.Client # 2 was admitted to the detoxification activity on May 1, 2025 and was discharged on May 5, 2025.Client # 3 was admitted to the detoxification activity on August 23, 2025 and was discharged on August 29, 2025.Client # 4 was admitted to the detoxification activity on December 12, 2024 and was discharged on December 18, 2024.Client # 5 was admitted to the detoxification activity on April 25, 2025 and was discharged on April 30, 2025.Client # 6 was admitted to the detoxification activity on November 11, 2024 and was discharged on November 8, 2024.Client # 7 was admitted to the detoxification activity on March 11, 2025 and was discharged on March 16, 2025.Client # 8 was admitted to the residential activity on July 22, 2025 and was active at the time of inspection.Client # 9 was admitted to the residential activity on July 15, 2025 and was discharged on July 20, 2025.Client # 10 was admitted to the residential activity on February 25, 2025 and was discharged on March 3, 2025.Client # 11 was admitted to the residential activity on June 3, 2025 and was discharged on June 23, 2025.Client # 12 was admitted to the residential activity on October 21, 2024 and was discharged on January 7, 2025.Client # 13 was admitted to the residential activity on November 27, 2024 and was discharged on December 22, 2024.Client # 14 was admitted to the residential activity on December 5, 2024 and was discharged on January 9, 2025.Client # 15 was admitted to the outpatient maintenance activity on November 13, 2024 and was discharged on February 7, 2025.Client # 16 was admitted to the outpatient maintenance activity on October 16, 2024 and was discharged on June 24, 2025.Client # 17 was admitted to the outpatient maintenance activity on October 29, 2024 and was active at the time of inspection.Client # 21 was admitted to the outpatient maintenance activity on November 19, 2024 and was active at the time of inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Records manager is responsible for chart document integrity. The recent transition from written to electronic health records (EHR) was a contributing factor in the documentation error. The corrected verbiage to the document regarding notification of client rights in the EHR was completed on-site by the vendor and Compliance Director during the survey on 9/10/25 and evidenced to the surveyor at the time as completed. These are hard-wired fixes and should not therefore reoccur, but random validation audits by the Compliance Analyst will continue for a period of 60 days to ensure ongoing compliance. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in two of six applicable client records reviewed. Client # 2 was admitted to the detoxification activity on May 1, 2025 and was discharged on May 5, 2025. There was no follow-up information documented in the record at the time of the inspection. Client # 3 was admitted to the detoxification activity on August 23, 2025 and was discharged on August 29, 2025. There was no follow-up information documented in the client record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The therapist is responsible for completion of attempted follow-ups with the client post-discharge. The Clinical Supervisor reviewed both the regulation and citations in the 2 records with the detox therapist and discovered that client #2 did have their follow-up form completed in the record; however, client #3 did not and this was subsequently completed by the detox therapist on 9/15/25. For compliance monitoring Clinical Managers are being informed daily of any counselors with missing/incomplete follow-ups and are responsible for conducting remediation with their staff as needed to ensure completion. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include the documentation of a discharge summary, in two of two applicable client records reviewed.Client # 15 was admitted to the outpatient maintenance activity on November 13, 2024 and was discharged on January 7, 2025. There was no discharge summary documented in the record at the time of the inspection.Client # 16 was admitted to the outpatient maintenance activity on October 16, 2024 and was discharged on June 24, 2025. There was no discharge summary documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The therapist is responsible for completion of a discharge summary. The Clinical Supervisor reviewed both the regulation and citations in the 2 records with the outpatient therapist for clients #15 and #16 which were subsequently completed by the outpatient therapist. For compliance monitoring Clinical Managers are being informed daily of any counselors who have missing/incomplete discharge documentation in their assigned records and are responsible for conducting remediation with their staff as needed. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include the documentation of follow-up information, in two of two applicable client records reviewed. Client # 15 was admitted to the outpatient maintenance activity on November 13, 2024 and was discharged on January 7, 2025. There was no follow-up information documented in the record at the time of the inspection. Client # 16 was admitted to the outpatient maintenance activity on October 16, 2024 and was discharged on June 24, 2025. There was no follow-up information documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The therapist is responsible for completion of attempted follow-ups with the client within 7 days post-discharge. The Clinical Supervisor reviewed both the regulation and citations in the 2 records with the outpatient therapist and both follow-ups for clients #15 and #16 which were subsequently completed by the outpatient therapist. For compliance monitoring Clinical Managers are being informed daily of any counselors who have missing/incomplete follow-ups in their assigned records and are responsible for conducting remediation with their staff as needed. |
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 an administrative review, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for failing to ensure all staff received communicable disease trainings within the regulatory timeframe for their position were submitted and approved by the Department for the August 27, 2024 through August 29, 2024 and September 7, 2023 through September 8, 2023 annual licensing renewal inspections. Failing to ensure all staff received communicable disease trainings within the regulatory timeframe for their position was again found to be a deficiency in the September 9, 2025 through September 12, 2025 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address deficiency in following prior approved POC and ensure follow-through of the POC moving forward, the Executive Director is responsible for and will conduct ongoing random compliance reviews of staff communicable disease trainings with the HR Director. Any findings will be immediately reviewed in the daily leadership meeting for follow-up remedial action by department heads with their respective staff responsible for such deficiencies. For PI purposes, POC data will be analyzed and findings reported monthly to leadership in Rehab Dashboard meetings for ongoing awareness and remediation (when necessary) in efforts to ensure deficiencies do not recur. Current staff who remain non-compliant must complete the required trainings by 10/31/25 or will not be allowed to work. |