INITIAL COMMENTS
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This report is a result of complaint investigation conducted on April 12, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Clem- Mar House, Inc. were substantiated. The following deficiencies were identified during this investigation.
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Plan of Correction
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705.7 (b) (2) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on the physical plant inspection, the facility failed to ensure that food preparation areas and appliances were cleaned after each usage.
The findings include:
An onsite complaint investigation was conducted on April 12. 2012. The kitchen area and appliances were inspected at that time. A counter top in the food preparation area near the stove was greasy and had a gritty substance on it ( possibly salt or sugar). Three refrigerators and freezers in the kitchen and great room areas were inspected. Each had spills and dirt visible on the lowest shelf area at the time of inspection. The inside of the range hood was observed to have a film of grease on it at the time of inspection.
Staff accompanied Division staff on the physical plant tour and did not dispute the findings.
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Plan of Correction
On April 14, the weekend resident manager oversaw the full "superclean" of the client cooking area, degreasing, sanitizing and scrubbing every area.
To prevent recurrence, the Resident Manager on duty at all meal times will inspect the kitchen after post-meal cleanup has been completed to ensure that all surfaces are clean, sanitary and grease-free. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of administrative materials and interviews with individuals at the facility, the facility failed to ensure that client rights were protected at all times.
The findings include:
An onsite complaint investigation was conducted on April 12, 2012. Three clients and four staff were interviewed. The interviews revealed that a "lock down" occurred at the facility in the past month. The lock down extended from March 7-10 , 2012. There was no policy or procedure in the facility manual regarding who has the authority to initiate this process, how it is to be administered or the duration of the process. Actual practice appears to be that the lock down affects all clients, though clients who have outside employment are given some consideration in regard to their work schedules.
The "lock down" process includes limiting activities such as telephone and television use. The client phone is reportedly removed during "lock down" so that those clients who have jobs or may have job interviews pending cannot be reached by employers or potential employers and cannot make contact with their sponsors in their twelve step programs. Additional restrictions occurring during a "lock down" include: no outside meeting attendance; clients up and out of their rooms at 7:00 PM and are not permitted back into their rooms until 10:30 PM; whole house cleaning; writing assignments; no radio use while working in the kitchen and no computer use.
This information was obtained from a hand written document that is generally posted in a staff office which outlined what is to occur in a "lock down". The document was made available during the staff and resident interview process. Documentation in staff logs verified that the "lock down" occurred.
Questionnaires presented to clients by staff as part of a survey taken by administrative staff and comments made by staff and clients during the interview process confirmed that staff have been condescending and demeaning in their communications with the client population.
Comments in client surveys and information provided in letters from clients to the personnel director indicated that staff "yell and scream", threaten "lock downs" and threaten "putting clients out" of the program if they don't listen. Documentation from the client surveys and from client letters back to the facility reflect that staff have degraded clients in front of others and have demeaned clients in public places.
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Plan of Correction
Prior to the state visit, the HR Director and Clinical Director were addressing behavioral issues on an individual basis - however, as client complaints did not list specific incidents, further action was not able to be taken. At the time of the survey, a mandatory training was already scheduled for 4/20/12 for all frontline staff. In addition, a meeting with the HR Director was scheduled for the weekly "cares & concerns" meeting with the clients for 4/18.
In regards to the "lock down" - the policy has been updated to reflect a "community sanction, which will be used as a therapeutic tool to encourage community cohesion, as needed, and determined by the clinical director of the facility." In addition, Resident Managers do not have the authority to terminate client treatment and all decisions for discharge rest solely in the hands of the clinical director. The clients were made aware of this during the full house meeting on 4/18, and it has been updated in the client handbook.
Based on the information rec'd in the complaints and data from the full-client meeting, on 4/20, a training was conducted that reinforced the tools given to the Resident Management staff to help manage difficult client behaviors and avoid confrontation. In addition, the training addressed - and reinforced- the existing CMH policies and procedures regarding client treatment, and the consequences of violation.
Each staff member was then asked to sign a "client treatment commitment" demonstrating their understanding of acceptable vs. unacceptable behavior.
The HR Director has reached out to the clients on a daily basis to ensure that the issues brought up on 4/18 have been addressed. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on interviews with clients and staff and documentation in client records, notification of termination was not done for all clients who were involuntarily discharged from the program.
The findings included:
Interviews were conducted with staff and clients during the onsite complaint investigation on April 12, 2012. Two clients (#1 & #2) had been involuntarily discharged at approximately 9 P.M. on the evening of April 11, 2012. The reason given for the discharge was that the clients failed to attend a mandatory "mock trial" being held at a local university and made mandatory by staff fiat. Facility policy included in the client handbook states that a client would receive a notice of discharge and that at that time the client would meet with staff to be informed of the behaviors and attitudes that were problematic.
Client files #1 and #2 were reviewed on April 12, 2012 and did not include documentation of notification of termination as required by facility policy communicated to clients on page 9 of the client handbook. There was no documentation anywhere in the client records or staff logs relating to the circumstances surrounding these discharges.
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Plan of Correction
The clinical director has addressed with the full clinical and residential staff on 4/13/12 the concern with documenting client's "negative" actions in treatment as well as positive to ensure that a clearer picture of behavioral issues, etc., is evident in the client's chart and retrained staff on the regulation that staff will ensure that all involuntarily terminated clients will receive a termination letter with reason for discharge and the right to appeal the termination prior to being terminated.
In addition, the only individuals with the authority to involuntarily discharge a client are the clinical director(s), clinical supervisor, and facility director. In the event that they not be on-site at the time of discharge, it will be clearly documented which member of the clinical supervisory team approved the discharge.
To prevent recurrence of this issue, the clinical director of the facilty met with the full resident management staff on 4/30/12 to rettrain on detailed documentation in daily tech reports to ensure that behavioral issues are seen and addressed by the clinical staff and that, in the event of (an approved, clinical) discharge, individuals who are tasked with it ensure all clients rec'v. proper documentation per CMH and The Department's Policies & Procedures.
In addition, on 4/25/12, the clinical directors of each facility - with the approval of the president of the board/project director updated the client handbook to help clarify reasons for discharge to prevent client confusion should issues like this arise in the future. |
709.17(a)(8) 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:
(8) Mistreating or abusing individuals cared for or treated by the facility.
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Observations
Based on the review of administrative documents, client records and interviews with staff and clients, the facility failed to ensure that clients were not mistreated or abused.
The findings include:
Four staff and three clients were interviewed during the onsite complaint investigation conducted on April 12, 2012. Various administrative documents, staff logs and client records were also reviewed. The Personnel Director confirmed during an interview that some of the concerns addressed in the complaint regarding treatment of clients had come to her attention in the recent past. The Personnel Director indicated that administrative staff were taking steps to intervene which would include a survey of current clients at the facility to ascertain what was occurring.
The Personnel Director presented copies of a survey given to clients. The materials presented included the anonymous hand written comments by the clients as well as a typewritten summary of the comments done by the sponsor of one of the clients. Comments from the clients on the survey indicated that staff frequently use profanity directed at the clients, but then sanction clients for using profanity themselves. Clients commented in writing and through interviews about being demeaned in front of other clients and in public by facility staff. Clients also observed that staff often use threats and intimidation to control them. The threats include the use of written sanctions, termination from the program and "lock downs".
Clients verbalized in interviews that staff act on a whim in regard to involuntarily terminating clients. One instance of this was the discharge of a client documented in a staff log . Client # 4 was discharged involuntarily on 1/27/12 for having a wireless Internet device near his bed. The discharge took place despite the lack of any documented rules regarding computer use.
Interviews with clients and staff disclosed that on the evening of April 11, 2012 at approximately 9:00 PM two clients were involuntarily discharged from the program for not attending a "mock trial" at a local university that was made a mandatory requirement by staff arbitrarily. Client records # 1 & # 2 were reviewed. There was no documentation in the staff logs or client records explaining the details surrounding these involuntary discharges. There was no documented evidence that the staff attempted to discuss the issues with clients. The results of the staff interviews suggested that the clients were uncooperative with making aftercare arrangements after they were told to pack their belongings because they were being discharged. There was no documentation of arrangements for lodging or aftercare for clients # 1 and #2. They were discharged onto the street with no after care arrangements.
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Plan of Correction
On 4/25, the Clinical Directors of each facility reviewed and updated the client handbook (with review and approval of the president of The Board/Project Director) to ensure that the information available to the clients is clear, understandable, and contains the most up-to-date information. This updated handbook will be presented to the clients at the weekly "rules meeting" on Saturday, April 28.
Part of this update includes the updated verbiage on ban of client access to internet-accessible devices, as well as clarification on what is commonly referred to as a "lock down" but is, in fact, a full-community sanction - used as a therapeutic tool and not a means of punishing the clients.
In addition, the full staff was trained on appropriate documentation procedures on 4/30/12 by the Clinical Director of the facility to ensure that any/all concerns with client behaviors are addressed not only in client charts but daily tech logs - to ensure that sanctions against residents are documented in a way that is consistent with the policy/procedure on which the sanction is based.
A complete staff training was conducted by the HR Director and Clinical Directors of each facility on 4/20/12, focusing on client treatment.
The client treatment training included verbatim statements from clients regarding concerns expressed to HR and The Clinical Director, a detailed understanding of the difference between clinical and support staff roles.
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From the training materials:
"Client Treatment is our #1 Priority. They are the reason we are here, and the reason we have continued our mission through a variety of circumstances over the last 18 years. Clients will always come first, and our employee handbook outlines the essential nature of client treatment in the following areas:
PRINCIPAL OFFENSES AGAINST CLEM-MAR HOUSE, INC.
(page 15 in employee handbook)
The following list includes the principal offenses against Clem-Mar House, Inc., discipline, as established by the corporation. Punishment for these offenses shall be subject to disciplinary action up to, and including, termination:
#5: Use of vile, intemperate, or abusive language, or acting in a disrespectful manner to any...client.
#9: Threatening, intimidating, or coercing a...client.
#10: Violence, Disorderly Conduct, Profanity, Inappropriate Vocal Conflict
#15: Unauthorized disclosure of any agency business, to include, but not exclusive to:
client information, funding information, programmatic concerns, staffing issues, clinical information, wages and salaries
#21: Any willful act, neglect, abuse or conduct detrimental to client care of Clem-Mar House, Inc., operations.
#24: Failure to render a personal service to any client if such service is within the normal and usual scope of the employee's duties or is required by reason of an emergency
relating to the client.
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To monitor staff compliance, the HR director will continue daily communication with the cilent base to address issues regarding customer treatment that violate policy as they happen to prevent recurrence of the issue at hand. |