INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17 through November 20, 2009 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on December 18, 2009.
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Plan of Correction
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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records, the facility failed to ensure that the clinical supervisor had the required clinical supervision training in one of three personnel records reviewed.
The findings include:
Twelve personnel records were reviewed on November 17, 2009. Three of the twelve were clinical supervisors and one of the three were required to have clinical supervision training. Employee #3 was hired on 9/5/03 and promoted to clinical supervisor on 7/30/05. The facility did not document two years of prior supervisory experience in the provision of clinical services prior to the promotion to clinical supervisor. In addition, an interview took place on November 16, 2009 with the Facility Director who confirmed that employee # 3 had not received the core curriculum training.
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Plan of Correction
1. The Clinical Operations Supervisor will monitor the website maintained by the Pennsylvania Bureau of Drug and Alcohol Programs to determine upcoming training dates.
2. The Clinical Operations Supervisor will notify the Project Director of the upcoming trainings and schedule those supervisors required to attend.
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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 personnel record, the facility failed to make sure that staff is trained for 6 hours in HIV/AIDS and at least 4 hours of TB/STD training in the required amount of time in twelve of twenty two records reviewed.
Findings:
Twenty-two personnel records were reviewed on November 17, 2009. HIV/AIDS and TB/STD training were required in twenty-two records. An interview with the Project Director was conducted on November 17, 2009 and he stated that the facility is currently working to get everyone updated with the required HIV/AIDS and TB/STD training by the next inspection.
Employee #6 was hired December 12, 1999 and was required to have HIV/AIDS & TB/STD training by December 12, 2000 and as of November 17, 2009 did not have the required training for HIV/AIDS.
Employee #8 was hired on August 11, 2008 and was required to have HIV/AIDS & TB/STD training by August 11, 2009 and as of November 17, 2009 did not have the required training for TB/STD.
Employee #13 was hired on October 21, 2002 and was required to have HIV/AIDS & TB/STD training by October 21, 2004 and as of November 17, 2009 did not have the required training for TB/STD.
Employee #14 was hired on April 19, 2005 and was required to have HIV/AIDS & TB/STD training by April 19, 2007 and as of November 17, 2009 did not have the required training for HIV/AIDS & TB/STD.
Employee #15 was hired on March 22, 2006 and was required to have HIV/AIDS & TB/STD training by March 22, 2008 and as of November 17, 2009 did not have the required training for HIV/AIDS.
Employee #16 was hired on September 16, 2002 and was required to have HIV/AIDS & TB/STD training by September 16, 2004 and as of November 17, 2009 did not have the required training for HIV/AIDS & TB/STD.
Employee #17 was hired on August 8, 2007 and was required to have HIV/AIDS & TB/STD training by August 8, 2009 and as of November 17, 2009 did not have the required training for HIV/AIDS.
Employee #18 was hired on May 3, 2004 and was required to have HIV/AIDS & TB/STD training by May 3, 2006 and as of November 17, 2009 did not have the required training for HIV/AIDS.
Employee #19 was hired on October 10, 2000 and was required to have HIV/AIDS & TB/STD training by October 10, 2002 and as of November 17, 2009 did not have the required training for HIV/AIDS.
Employee #20 was hired on October 13, 2003 and was required to have HIV/AIDS & TB/STD training by October 13, 2005 and as of November 17, 2009 did not have the required training for HIV/AIDS & TB/STD.
Employee #21 was hired on November 29, 1998 and was required to have HIV/AIDS & TB/STD training by November 28, 2000 and as of November 17, 2009 did not have the required training for HIV/AIDS.
Employee #22 was hired on October 21, 2002 and was required to have HIV/AIDS & TB/STD training by October 21, 2004 and as of November 17, 2009 did not have the required training for TB/STD.
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Plan of Correction
1. Since 2007, the facility has been offering the mandatory sic-hour HIV/AIDS training and the mandatory four-hour TB/STD training for up to 25 employees each quarter.
2. The facility failed in an appeal in 2008 to define those employees required to attend the trainings as those who have direct contact -- as distinct from indirect contact -- with patients. Because of the broader definition of those employees required to have the training, the facility will continue to offer the mandatory trainings on a quarterly basis and require employees to attend.
3. Monitoring will be completed by the Director of Human Resources, who will report on a quarterly basis the list of attendees for that quarter and the list of those still required to participate. The report will made to the Executive Committee, internally called Dashboard, for monitoring and oversight.
4. The Executive Director and the Human Resources Director have selected the following four months for the mandatory trainings to be conducted: March 2010, June 2010, September 2010 and December 2010.
5. The Executive Director and the Human Resources Director have ranked employee positions in terms of first tier, those required to have the mandatory trainings within the first year; and second tier, those required to have the mandatory trainings within the first two years.
6. Also receiving priority in scheduling staff for the trainings are those employees who have worked with the company more than two years, who have not completed the mandatory trainings.
7. Beginning in 2009, the facility broadened its staff requirements by requiring the following departments complete the mandatory trainings: Dietary, Security, IT, Medical Records and Housekeeping. Previously, employees in these departments were not required to participate in the mandatory trainings. |
709.123(c)(5) LICENSURE Follow-up information
709.123. Treatment and rehabilitation.
(c) Client records. 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:
(5) Follow-up information.
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Observations
Based on a review of twenty-one, nine records were reviewed from the psychiatric unit. Of these nine records three were reviewed for discharge content. In accordance with the facility's policy follow documentation will be done within seven days of discharge. The facility failed to document follow-up information in three of three client records.
The findings include:
Nine records were reviewed on November 19, 2009 through November 20, 2009. Follow-up were required in three client records, #7, 8 and 9.
Client record #7 was discharged on 2/5/09 and as of to date documentation of follow-up was not documented.
Client record #8 was discharged on 3/4/09 and as of to date documentation of follow-up was not documented.
Client record #9 was discharged on 9/4/09 and as of to date documentation of follow-up was not documented.
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Plan of Correction
1. The Director of Social Services/Utilization Management will train the Social Work staff on the psychiatric units in the requirement that a seven-day follow-up be completed on all patients with co-occurring disorders who are covered under both the Department of Health and the Department of Public Welfare licenses.
2. Monthly, the Director of Social Services/Utilization Management will develop a list of discharged patients who were treated for their co-occurring disorders.
3. The list will be provided monthly to the Medical Records Department. Medical Records staff will document the presence of a seven-day follow-up for each discharged patient on the list.
4. The results of the closed-chart audits will be reported monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs on November 17, 2009 and interview with the facility director and project director, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
A review of the fire drill logs was conducted on November 17, 2009. Documentation of a fire drill conducted during sleeping hours is required once every six months. The facility failed to document any fire drills during sleeping hours in the last twelve months, from November 2008 through November 2009. Staff interviews further revealed the sleeping hour fire drills did not occur during the above specified time period.
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Plan of Correction
1. The facility conducts fire drills monthly, and once each shift on a quarterly basis.
2. Because of the large number of patients with sleeping problems, the Project Director decided to conduct the third-shift drill each quarter to coincide with the wake-up time for patients. This practice will be discontinued.
3. Beginning in 2010, the facility will conduct fire drills between 11 p.m. and 6 a.m., which is wake-up time for patients to ensure compliance with the requirement. The third-shift sleeping hours drill will be continued on a quarterly basis.
4. Fire drill reports are made monthly to the Safety Committee by the Supervisor of Security. The Safety Committee will monitor compliance. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative materials and an interview with the Project Director on November 17, 2009, the facility failed to document an annual audit of financial activities for the year ended June 30, 2008.
The findings include:
During the onsite licensing inspection on November 17 through November 20, 2009, the administrative materials were reviewed and no documentation of an annual audit was located. The project director was interviewed about the documentation of the annual audit and he indicated that no audit was documented for the fiscal year ended June 30, 2008.
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Plan of Correction
The company did conduct an annual audit for fiscal year 2008, but has not yet completed any financial review of discal year 2009. Mayer Hoffman McCann PC has been engaged to conduct a financial review for fiscal year 2009. The report is expected to completed by June 30, 2010. |
709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of twenty-one, five records were reviewed from the non hospital-short term detoxification unit. The facility failed to complete psychosocial evaluations in five of five client records.
Findings:
Five client records were reviewed on November 19, 2009 through November 20, 2009. Psychosocial evaluations were required in five client records. The counselors did not evaluate the clients when it came to the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselors conclusion/impressions of the client in records #10, 11,12 and 13. The psychosocial evaluations contained no evaluative information but rather listed or restated information gathered in the client histories.
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor on a bi-weekly basis will review the clinical evaluation contained in the Psychosocial Assessment for quality of clinical assessments.
2. The clinical team will review 10 percent of randomly selected open charts. The focus of the review will be assess the clinical conceptualization and evaluative information the the primary therapists have develoed based uponh reported patient information and history. The purpose of the audit is to help ensure that the evaluations are not simply a recitation of facts, but true assessments that include, but not limited to:
A. The patient's problems and needs
B. The patient's assets/strengths
C. The patient's support systems
D. coping mechanisms
E. Negative factors affecting
treatment
F. The counselor's conclusions and
impressions.
3. Results of the biweekly audits will be provided monthly for four months to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
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 twenty-one, five records were reviewed from the non-hospital short term detoxification unit. Of these five records, two were reviewed for discharge content. In accordance with the facility's policy follow-up documentation will be done within seven days of discharge; the facility failed to document follow-up information in two of two client records.
The findings include:
Five records were reviewed on November 19, 2009 through November 20, 2009. Follow-up were required in two client records, # 13 and 14.
Client record #13 was discharged on 5/25/09 and as of to date documentation of follow-up was not documented.
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will monitor completion of the seven-day follow-ups via the daily clinical treatment team meeting. The meeting includes the Medical Director, all Primary Therapists, the Resource Coordinator, the Utilization Management Coordinator and the clinical management leaders.
2. All follow-up forms will be due to clinical management within the first seven days post-discharge.
3. Clinical management will provide the complete seven-day follow-up forms to Medical Records Department staff, who complete the closed-chart audits.
4. Results of the audits will be provided monthly to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of twenty-one, seven records were reviewed from the residential treatment and rehabilitation unit. The facility failed to complete psychosocial evaluations in seven of seven client records.
Findings:
Seven client records were reviewed on November 19, 2009 through November 20, 2009. Psychosocial evaluations were required in seven client records. The counselors did not evaluate the client's when it came to the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselors conclusion/impressions of the client in client records #15, 16, 17, 18, 19, 20 and 21. The psychosocial evaluations contained no evaluative information but rather listed or restated information gathered in the histories.
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor on a bi-weekly basis will review the clinical evaluation contained in the Psychosocial Assessment for quality of clinical assessments.
2. The clinical team will review 10 percent of randomly selected open charts. The focus of the review will be assess the clinical conceptualization and evaluative information the the primary therapists have develoed based uponh reported patient information and history. The purpose of the audit is to help ensure that the evaluations are not simply a recitation of facts, but true assessments that include, but not limited to:
A. The patient's problems and needs
B. The patient's assets/strengths
C. The patient's support systems
D. The patient's coping mechanisms
E. Negative factors affecting
treatment
F. The counselor's conclusions and
impressions.
3. Results of the biweekly audits will be provided monthly for four months to the Executive Committee, internally called Dashboard, for oversight and monitoring.
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709.52(a)(1) LICENSURE Short/Long term TX Goals
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of twenty-one, seven records were reviewed from the residential treatment and rehabilitation unit. The facility failed to document short term goals with action steps in four of seven client records reviewed.
Findings:
Seven client records were reviewed on November 19, 2009 through November 20, 2009. Short and long-term goals were required in seven client records. Short term goals with action steps were not documented in client records, #16, 17, 18 and 19.
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will train therapists in the language of short- and long-term goals as they related to treatment planning.
2. Following the training, the supervisors will on a biweekly basis review with Primary Therapists the status of their creation of short- and long-term goals on the treatment plans.
3. Results of the biweekly reviews will be presented monthly for four months to the Executive Committee, internally called Dashboard, for oversight and monitoring. |
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
Based on a review of twenty-one, seven records were reviewed from the residential treatment and rehabilitation unit. The facility failed to document a complete treatment plan update in two of seven client records where required.
Findings:
Seven client records were reviewed on November 19, 2009 through November 20, 2009. Treatment plans updates were required in two client records. In client records #15 and 18 treatment plan updates did not include the client's progress in relationship to the stated goals of the treatment plan, but rather stated generalized comments that were not specific to the client's progress in treatment.
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Plan of Correction
1. The Facility Director, the Clinical Director and the Clinical Operations Supervisor will review with Primary Therapists the updated treatment plans on a biweekly basis.
2. The review will ensure completion of the updated treatment plans in a timely manner and will ensure that the patient's progress or lack of progress on previous treatment goals and objectives is documented.
3. Results of the biweekly reviews will be presented monthly for four months to the Executive Committee, internally called Dashboard, for oversight and monitoring. |