INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the September 12, 2011 licensure follow-up inspection. The follow-up inspection was conducted on February 23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Clem-Mar House Inc. 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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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 client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment and the counselor conclusions and or impressions of the client in eight of eight client records.
The findings include:
Sixteen client records were reviewed on February 23, 2012. A psychosocial evaluation was required in eight of those records, #1, 2, 3, 4, 5, 6, 7 and 8. An interview with the facility staff on February 23, 2012 confirmed the findings.
Client records #1, 2, 3, 4, 5, 6, 7 and 8 failed to document an evaluation of the client's assets/strengths.
Client records #1, 2, 3, 4, 6, 7 and 8 failed to document an evaluation of the client's support systems.
Client records #1, 2, 3, 4, 6, 7 and 8 failed to document an evaluation of the client's coping mechanisms.
Client records # 1, 2, 3, 4, 5, 6, 7 and 8 failed to document an evaluation of the client's negative factors and how they could inhibit treatment.
Client records # 5 and 6 failed to document an evaluation of the client's attitude towards treatment.
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Plan of Correction
The clinical directors from each facility have met with clinical team on 3/21 to implement more detailed client charting, including coaching and retraining to more detailed documentation and assessment of the information provided in the psychosocial data package filled out by clients in the clinical diagnostic portion of the psychosocial process.
Clinical Director will continue to monitor all client charts on a weekly basis to ensure compliance, as well as reinforce proper procedures in weekly supervision sessions to prevent recurrence. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to complete an aftercare plan in seven of eight discharge records reviewed.
The findings include:
Sixteen client records were reviewed on February 23,2012. Aftercare plans were required in client records # 9, 10, 11, 13, 14, 15, 16 . The facility failed to document time frames of completion of the stated goals. Per the facility policy and procedure manual, aftercare plans are to be completed prior to the client's discharge date. An interview with the facility staff on February 23, 2012 confirmed the findings.
Client #13 was discharged on January 17, 2012 and an aftercare plan was not documented.
Client #9's aftercare plan was completed on January 13, 2012 and the goals were documented but did not document the time frames which is required in the client's aftercare plan.
Client #10's aftercare plan was completed on January 23, 2012 and the goals were documented but did not document the time frames which are required in the client's aftercare plan.
Client #11's aftercare plan was completed on January 12, 2012 and the goals were documented but did not document the time frames which are required in the client's aftercare plan.
Client #14's aftercare plan was completed on January 24, 2012 and the goals were documented but did not document the time frames which are required in the client's aftercare plan.
Client #15's aftercare plan was completed on January 30, 2012 and the goals were documented but did not document the time frames which are required in the client's aftercare plan.
Client #16's aftercare plan was completed on January 24, 2012 and the goals were documented but did not document the time frames which are required in the client's aftercare plan.
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Plan of Correction
To prevent recurrence of violation of the CMH Aftercare Policy has been edited on 3/21/2012- removing the need for unnecessary client aftercare plans to avoid the inability to correctly update on those individuals who do not require aftercare documentation.
The clinical director of the facility has coached/retrained the counselors to the appropriate timing and completion as such.
The clinical directors of each facility will review/approve client aftercare plans at least one week prior to client discharge going forward to ensure that, should the information on the plan not meet the specifics, a counselor can edit and correct before client's program completion. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 complete the discharge summaries in seven of eight discharge records reviewed.
The findings include:
Sixteen client records were reviewed on February 23, 2012. Discharge summaries were required in client records # 9, 10, 11, 12, 13, 14, 15 and 16. The facility failed to document the client's reason for treatment and services offered to the client. Per the facility policy and procedure manual, discharge summaries will be documented within 7 days after the client is discharged from the program. An interview with facility staff on February 23, 2012 confirmed the findings.
Client #10 was discharged on January 23, 2012 and the facility failed to document the reason for treatment on the discharge summary.
Client #11 was discharged on January 18, 2012 and the facility failed to document the reason for treatment on the discharge summary.
Client #12 was discharged on January 17, 2012 and the facility failed to document the reason for treatment on the discharge summary.
Client #13 was discharged on January 21, 2012 and the facility failed to document the reason for treatment on the discharge summary.
Client #14 was discharged on January 24, 2012 and the facility failed to document the reason for treatment on the discharge summary.
Client #15 was discharged on February 1, 2012 and the facility failed to document the reason for treatment on the discharge summary.
Client #16 was discharged on February 1, 2012 and the facility failed to document the reason for treatment on the discharge summary.
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Plan of Correction
The clinical directors from each facility have met with clinical team on 3/21 to implement more detailed client charting, including coaching and retraining to the expectations of documentation in a client's "reason for treatment" - i.e. the specific instances that generated a clients journey to a halfway house environment.
Clinical Director will continue to monitor all client charts on a weekly basis to ensure compliance, as well as reinforce proper procedures in weekly supervision sessions.
To prevent recurrence, The Clinical Director will review Discharge Summaries within 7 days of completion to ensure all information is appropriately documented. |