INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2010 through July 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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 and a plan of correction is due on July 27, 2010.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of employee personnel and training records and an interview with the Assistant Project Director, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.
The findings include:
During the onsite licensing inspection of a review of employee # 3's training record indicated that no supervisory notes were documented for the initial six months of employment as Clinical Supervisor. Employee # 3 became employed at Clem-Mar House on 8/24/2005. Employee # 3 was promoted to Clinical Director on 3/15/2010. As of the date of the inspection, the facility did not document monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position. An interview with the Assistant Project Director on 6/30/2010 at 3:55 p.m. confirmed that these supervisory sessions were not held.
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Plan of Correction
Due to an error by the Assistant Project Director, these Supervisory meetings never took place. These six Monthly meetings will begin 07/12/1- and conclude no later then 01/12/11. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor met the qualifications for the position in two of two personnel records.
The findings include:
On June 30, 2010 seven personnel records were reviewed. Two personnel records were required to have documentation of the qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel records # 4 and 5.
Employee # 4 was hired as a counselor on December 15, 2009. Employee # 4 has a Bachelor of Science in Social Work which meets the educational requirements; however, employee #4 does not have the one year of clinical experience in a health or human service agency. The only clinical experience this employee has is the six months of clinical work that they have received while employed at this agency.
Employee # 5 was hired as a counselor on May 25, 2010. Employee # 5 has a Bachelor of Arts in Psychology which meets the educational requirements; but does not have one year of required clinical experience. Employee # 5 only has one month of clinical experience; which does not meet the minimum requirements for the position of counselor and this experience is the experience that they received while employed at this agency.
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Plan of Correction
Employee #4 and Employee #5 were reduced to Counselor Assistant Positions on 07/01/10. An exception will be filed on behalf of both employees by 07/29/10. If the exceptions are not granted, since employee #4 received a positive evaluation by the Clinical Director on 07/05/10 stating she is capable of handling a full caseload, and besides the Clinical Director, Clem-Mar House also has an Assistant Project Director with a C.A.C. to supervise employee #5, we will meet the proper staffing levels. In the future only Counselors will be hired who have one year Drug and Alcohol experience and meet the qualifications as deemed necessary by the department for the position of counselor. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records, CPR/first aid certification cards and an interview with the Assistant Project Director, the facility failed to ensure that a sufficient number of staff persons were trained in first aid.
The findings include:
Employee CPR/first aid certification cards were reviewed on July 1, 2010 along with the past four weeks of the resident manager schedule. The facility failed to have first aid coverage on third shift on the following days: 5/29/2010, 5/30/2010, 6/5/2010, 6/12/2010, 6/13/2010, 6/19/2010, and 6/26/2010. The facility failed to have first aid coverage on second shift on 5/31/2010. The Assistant Project Director confirmed that the facility did not have a first aid card for employee # 7 who was scheduled for the aforementioned shifts.
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Plan of Correction
The employee in question failed to attend a scheduled training. The employee was removed from the work schedule on 06/30/10. The employee is again scheduled for First Aid Training on 07/13/10 and will not be allowed to work alone again until his attendance can be verified. In the future no employee will be allowed to work shifts alone without a valid CPR Certification or First Aid Card. In the future any employee who misses a scheduled training will be removed from the work schedule until they complete that training on their own. This will be monitored by the Assistant Project Director. |
704.11(d)(1) LICENSURE Training Req-Proj/Fac Directors
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
Based on the review of personnel and training records the facility failed to provide a training plan for the Project Director.
The findings include:
The facility personnel records and training plans were reviewed on June 30, 2010. Documentation was not provided for the training plan for employee # 1 which made it difficult to determine if the subject areas of any training obtained were selected according to the individual training plan.
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Plan of Correction
The Project Director failed to provide a Training Plan for the previous year trainings. The Project Director will develop a Training Plan for the next year of training on 07/12/10. In the future, the Office Manager will ensure this is completed on an annual basis. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
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Observations
Based on a review of current client census information, clinical staff hours and an interview with the facility director, the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every ten clients, as required by the exception the facility received to this regulation.
The findings include:
The current client census information and clinical staff hours were reviewed on June 30, 2010. Per regulation, inpatient non hospital treatment and rehabilitation projects serving adult clients shall have one FTE counselor for every eight clients; however, this facility has an exception to have one FTE counselor for every ten clients. The facility employed two counselors; however, the both counselors that were reviewed (employee # 4 and employee # 5) did not meet the requirements to be a counselor and could not be included in the equation to determine the client counselor ratio. Based on this information, the staff client ratio was 40:1; which exceeded the required 10:1 ratio.
Employee # 1 works 15 hours with clients and employee # 2 works 10 hours with the clients. (25/40=.625 FTE 25 clients/ .625 FTE = 40:1 caseload)
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Plan of Correction
Employee #4 received a positive assessment by the Clinical Director on 07/05/10 stating she is capable of handling a full caseload. Also, the Assistant Project Director has a C.A.C. and is able to suipervise employee #5. Clem-Mar House is again at a client/Counselor ratio of 10:1. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on the physical plant tour and an interview with the Assistant Project Director and Clinical Director, the facility failed to have a bedroom equipped with a mechanism for hearing impaired persons to be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
The finding include:
A physical plant tour was conducted on July 1, 2010 between the hours of 8:20 a.m. and 8:45 a.m. An interview with the Assistant Project Director and Clinical Director at 8:35 a.m. confirmed that the facility failed to maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire. The facility failed to have a client bedroom equipped with assistive devices to alert those with hearing impairment in event of a fire.
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Plan of Correction
Strobe lights are being placed in bedroom #1 where all hearing impaired clients will be placed. This work will be completed by 09/01/10. Until then, Clem-Mar House will not accept any clients with hearing impairments. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative policy and procedures and an interview with the Assistant Project Director, the facility failed to include the project director's signature on a completed annual update of the written policy and procedures manual.
The findings include:
The administrative policy and procedures were reviewed on June 30, 2010. The project director failed to document the annual update of the written project policies and procedures, as required by regulation.
The Assistant Project Director was interviewed on June 30, 2010. He confirmed that the last time the policy and procedure manual was annually updated and signed off by the Project Director was August 29, 2007.
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Plan of Correction
The Project Director mistakingly failed to sign the Policy and Procedure Manual since 09/04/07. The project Director will update and sign the Policy and Procedure Manual on 07/12/10, and annually after that. The Assistant Project Director will be responsible for making sure this occurs in the future. |
709.26(b)(4) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(4) The implementation of Federal, State and local statutes concerning fair employment practices.
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Observations
Based on a review of the policy and procedure manual, an interview with the assistant project director, and administrative documentation, it was determined that the facility failed to demonstrate the implementation of fair employment practices.
The findings were:
The policy and procedure manual was reviewed on June 30, 2010. Administrative documentation demonstrating the implementation of fair employment practices dated September 4, 2007 was provided in the policy and procedure manual. According to the facility policy and procedure manual, the project director or his/her designee shall prepare a quarterly report giving a breakdown of the staff compositions in regard to age, sex and race. The facility failed to follow their policy and presented documentation that was outdated and did not fairly represent the current staff members. The assistant project director confirmed that the documentation presented to the licensing specialist was the last documented equal employment opportunity grid that had been prepared.
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Plan of Correction
The Project Director and Assistant Project Director each thought the other was doing this. The Executive Assistant maintains physical control of the Policy and Procedure Manual and failed to mention that this quarterly report was not being completed. The Assistant Project Director will be responsible for generating this report beginning 07/12/10. In the future the Assistant Project Director will be responsible for generating this quarterly report. Compliance will be monitored by the Office Manager. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records, the facility failed to document the results of a reference investigation in three of seven personnel records.
The findings include:
Seven personnel records were reviewed on June 30, 2010. Seven personnel records required reference investigations. The facility failed to document reference investigations in employee records # 4, 5, and 6.
Employee # 4 was hired on December 15, 2009. There was no documentation of a reference investigation.
Employee # 5 was hired May 25, 2010. There was no documentation of a reference investigation.
Employee # 6 was hired May 24, 2009. There was no documentation of a reference investigation.
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Plan of Correction
The Assistant Project Director mistakingly failed to ensure reference checks on these three employees were documented. Reference checks on these three employees will be documented by 07/12/10. In the future, no employee will be allowed to start work until his reference checks are completed and documented. The Assistant Project Director will be responsible for making these reference checks in the future. Compliance will be monitored by the Office Manager. |
709.29(a) & (b) LICENSURE Retention of Client Records
709.29. Retention of client records.
(a) Client records, whether original, reproductions or microfilm, shall be kept on file for a minimum of 4 years following the discharge of a client.
(b) If the project discontinues operation, it shall make known to the Department where its records are stored.
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Observations
Based on the review of the facility policy and procedure manual, the facility failed to have a policy in place to notify the department of where its records are stored if the project discontinues operation.
The findings include:
The facility policy and procedure manual was reviewed on June 30, 2010. The facility failed to have a policy in place that indicated that they would notify the Department if the project discontinues operations to let the Department know where its records are stored.
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Plan of Correction
An addition will be made to the Policy and Procedure M
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on client record reviews and a conversation with the staff, the facility failed to document a follow-up attempt in three of three required client records.
The findings include:
Six client records were reviewed on July 1, 2010. Three of the client records reviewed were discharged records. A follow-up attempt was required in three of the client records. According to the facility policy and procedure manual, follow-up attempts shall be made one week, one month and three months post discharge. The facility did not document a follow-up attempt in three of three discharged client records, specifically # 4, 5, and 6.
Client # 4 was admitted on 6-16-2010 and discharged on 6-20-2010. A follow-up attempt was due on 6-27-2010. There was no documentation of a follow-up attempt for this client at the time of the inspection.
Client # 5 was admitted on 3-9-2010 and discharged on 4-22-2010. A follow-up attempt was due on 4-29-2010 and 5-22-2010. There was no documentation of follow-up attempts for this client at the time of the inspection.
Client # 6 was admitted on 3-1-2010 and discharged on 5-28-2010. A follow-up attempt was due on 6-4-2010 and 6-28-2010. There was no documentation of follow-up attempts for this client at the time of the inspection.
The Assistant Project Director was present when the resident manager reported that the follow-up attempts were not available for client record # 4, 5, and 6.
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Plan of Correction
The Resident Manager/Intake Coordinator failed to document that the follow-ups were attempted but the phone was not answered in all three cases. Follow-up phone calls were again made on 07/09/10 with no answer again from all three clients. In the future the Clinical Director will be responsible for ensuring that all folliow-ups are completed and documented. |