INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on July 5 through 6, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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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704.8(a)(1) - (5) & (b) LICENSURE Qualification Level
704.8. Qualifications for the position of counselor assistant.
(1) A Master's Degree in a human service area.
(2) A Bachelor's Degree in a human service area.
(3) Licensure in this Commonwealth as a registered nurse.
(4) An Associate's Degree in a human service area.
(5) A high school diploma or General Education Development (GED) equivalent.
(b) A counselor assistant shall also complete the training requirements in 704.11 (relating to staff development program).
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Observations
Based upon a review of the Staffing Requirements Facility Summary Report (SRFSR) and employee records, the facility failed to verify that an employee promoted to the position of counselor assistant met one of the qualifications for the position.
The findings include:
The SRFSR and two employee records requiring verification of employment qualifications were reviewed on July 5, 2012.
One of two records, specifically # 4, did not include verification that the employee met the qualifications for the position of counselor assistant.
The SRFSR listed employee # 4 as having a high school diploma.
Employee # 4 was hired by the project on September 13, 2012, and promoted to the position of Counselor Assistant on May 14, 2012. As of the date of inspection, the record did not include documentation that verified that employee # 4 had obtained his high school diploma or General Education Development equivalent. In addition, the record did not contain verification that the employee met any of the other qualifications for the position of counselor assistant.
The findings were confirmed by the Human Resources Director during the exit interview.
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Plan of Correction
Employee # 4 obtained, and provided, a copy of their official high school transcripts on 7/9/12. To prevent recurrence, the HR Director will review all non-graduate Counselor's Assistant candidate personnel records prior to hire to ensure that all information required is up to date and, should a diploma not be available, will request a HS Transcript. The CA Will not be eligible to begin in their position until said information is received. |
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 upon a review of the facility's Staffing Requirements Facility Summary Report (SRFSR) and an exception granted for the client to counselor ratio, the facility failed to ensure that the client to counselor ratio remained at or below 10:1.
The findings include:
The facility was granted an exception to the requirement for an 8:1 client to counselor ratio and is permitted to maintain a 10:1 ratio.
The SRFSR was reviewed on July 5, 2012. The SRFSR included documentation of 2.05 FTE counselors for the facility. The SRFSR also listed the current client census at 21. The client to counselor ratio is equal to 21 divided by 2.05, which is an 11:1 ratio. Therefore, the facility exceeded its approved client to counselor ratio.
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Plan of Correction
On August 15, 2012 the Clinical Director provided supervision to the counselor's assistant whose schooling information was previously provided. In that supervision session, the clinical director provided a positive assessment of the CA's capabilities and his ability to handle a caseload of 7 clients. In addition, on August 13, 2012, a Counselor's Assistant was replaced with a full counselor, which brings the ratio up to date.
To prevent recurrence, future CA's will not be assigned a caseload until clinical director provides a positive assessment of their ability to maintain an appropriate caseload.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that all trash, garbage and rubbish was stored in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
The findings include:
The physical plant inspection was conducted on July 6, 2012, between 10:30 AM and 11:30 AM. The Clinical Director accompanied the Licensing Specialist during the inspection of the exterior of the physical plant.
The facility stores its trash, garbage, and rubbish in a dumpster that is located across the street from the facility. At the time of inspection, three out of four of the dumpster's lids were not closed and two out of the three lids that were not closed were propped up by trash being stored inside the dumpster. As a result, insects and rodents had access to the trash, garbage and rubbish contained in the dumpster.
The findings were confirmed by the Clinical Director during the physical plant inspection.
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Plan of Correction
Collection days for the waste are Mondays and Fridays weekly. All garbage was removed from The Facility's Dumpster on 7/9/12.
To prevent recurrence, on Holiday weeks, and at times when the dumpster approaches capacity going forward, to prevent recurrence, the Senior Resident Manager will make arrangements to have trash disposed of through the municipal garbage service.
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705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based upon the physical plant inspection, the facility failed to maintain at least one shower or tub for every eight clients.
The findings include:
The physical plant inspection was conducted on July 6, 2012, between 10:30 AM and 11:30 AM.
The facility's maximum capacity is 25 clients; therefore, the facility is required to maintain a minimum of three commodes, sinks, and showers or tubs.
The facility maintained three bathrooms for client use and each bathroom was equipped with one shower or tub. One bathroom was located on the floor bathroom and two bathrooms were located on the second floor. One of three showers or tubs, the shower located in the bathroom on the first floor, was not available for use at the time of inspection as it was being used to store painting supplies and the shower curtain was torn. Therefore, only two showers or tubs were available for client use at the time of inspection.
The findings were confirmed by the Clinical Director.
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Plan of Correction
Immediately after the survey, the senior resident manager and maintenance technician removed all obstructions for use in the client bathroom on July 6, 2012. In addition, the maintenance technician updated the shower stall, tile and paint in that restroom to refresh it for client use on July 9, 2012.
To prevent recurrence, Senior Resident Manager will inspect restroom on a daily basis to ensure that there are no obstructions to the client's ability to utilize that all 3 available showers, sinks, and toilets are available, free of obstruction, and able to be used on a daily basis.
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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 upon the physical plant inspection, the facility failed to ensure that all food preparation areas were cleaned and disinfected following each meal.
The findings include:
The physical plant inspection was conducted on July 6, 2012, between the hours of 10:30 AM and 11:30 AM. A Resident Manager, the Clinical Director, and the Human Resources Director were present for various portions of the inspection.
While inspecting food preparations areas in the dining room area, the Licensing Specialist noticed that the counter that contained the coffee maker and microwave oven was not clean as there were coffee stains and loose tobacco on the counter top.
The Resident Manager who was present during this part of the inspection confirmed the presence of the coffee stains and loose tobacco on the counter top.
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Plan of Correction
Immediately after the inspection on 7/6/12, the senior resident manager cleaned and sanitized the coffee area. In addition, the clinical director met with all clients to make them aware that tobacco products are not to be stored/rolled/placed anywhere near food storage or preparation areas. To prevent recurrence, senior resident manager will work with Community Leaders to inspect the coffee area twice daily going forward. |
705.7 (b) (5) 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:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based upon a review of facility temperature logs, the facility failed to keep frozen food at or below 0 Fahrenheit (F).
The findings include:
Temperature logs for eight facility freezers were reviewed on July 6, 2012. Logs for two of eight freezers, the freezer labeled "Pantry 1" and the freezer labeled "Great Room (redacted name brand) Freezer" contained documentation of temperatures above 0 F.
Temperatures for the freezer labeled "Pantry 1" exceeded 0 F on the following dates:
March 22, 2012 + 10 F
March 21, 2012 + 25 F
March 19 - 20, 2012 + 30 F
March 17 - 18, 2012 + 15 F
March 14 - 15, 2012 + 5 F
March 8, 10, 11, 2012 + 15 F
March 7, 9, 2012 + 10 F
March 6, 2012 + 5 F
March 5, 2012 + 10 F
March 3 - 4, 2012 + 15 F
March 2, 2012 + 8 F
March 1, 2012 + 10 F
Temperatures for the freezer labeled "Great Room (redacted name brand) Freezer" exceeded 0 F on the following dates:
July 6, 2012 + 20 F
July 1, 2012 + 38 F
June 30, 2012 + 10 F
June 2, 2012 + 10 F
May 20, 2012 + 10 F
April 14 - 19, 2012 + 10 F each day
March 28, 30, and 31 + 10 F each day
March 29, 2012 + 12 F
March 27, 2012 + 9 F
March 21 - 24, and 26, 2012 + 8 F
March 19, 2012 + 5 F
March 18, 20, and 25, 2012 + 10 F each day
March 17, 2012 + 8 F
March 14 - 15, 2012 + 10 F each day
March 12, 2012 + 40 F
March 6, 9, 10, and 11, 2012 + 10 F each day
March 5, 2012 + 5 F
March 3 - 4, 2012 + 10 F each day
March 2, 2012 + 4 F
March 1 2012 + 2 F
The findings were confirmed by the Resident Manager during the physical plant inspection.
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Plan of Correction
The freezer in the great room was examined by maintenance tech on July 9, confirming that the issue with the temperatures in the freezer were correct, but that the thermometer/temp gauge was broken, reflecting incorrect temperatures. In addition, the pantry freezer was defrosted on 7/9 and reset to high freeze to ensure that temperature remains 0 or below going forward.
A new thermometer was purchased on July 3, 2012 for the Great Room Freezer, and the temperature remained below 0 degrees F daily since that time. In addition, the time of day the temperature was verified was changed to 3 am daily, enabling a more accurate reading at a time when there would be no cause for the freezer to be accessed, causing fluctuation.
To prevent recurrence, Resident Managers are required to report any temperature above 0 degrees F to the senior resident manager and clinical director so that the freezer may be immediately repaired, as needed. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based upon the physical plant inspection, the facility failed to store all food items off the floor.
The findings include:
The physical plant inspection was conducted on July 6, 2012, between the hours of 10:30 AM and 11:30 AM. A Resident Manager, the Clinical Director, and the Human Resources Director were present during various parts of the inspection.
The facility stores non-refrigerated food items in a pantry that is located toward the rear of the first floor. Upon entering the pantry, the Licensing Specialist observed that an open bag of flour was being stored on the floor of the pantry.
The findings were confirmed by the Resident Manager who was present during the inspection of the pantry.
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Plan of Correction
On the date of the inspection, 7/6/12, the bag of flour was immediately removed from the floor of the pantry. In addition, on August 13, the senior resident manager purchased large Tupperware storage bins in which to store flour going forward.
Signs were also placed in the pantry area on August 10, 2012, to remind all clients that no food should be stored on floor of any area. To prevent recurrence, the 3rd Shift Resident Manager will inspect the pantry and all food storage areas to ensure that all dry goods are appropriate stored going forward. In addition, all resident managers on duty will inspect the kitchen and food storage areas immediately following meal cleanup to ensure that pantry/food storage areas remain clean and sanitary. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based upon a review of the facility's Policy & Procedures (P&P) Manual and employee records, the facility failed to document that all staff were trained in the use of the fire extinguishers as per facility policy.
The findings include:
The P&P Manual was reviewed on July 5, 2012. The facility's policy regarding fire extinguisher and fire / emergency training specifies that all employees are trained within 3 days of employment.
Two employee records requiring documentation of fire extinguisher training were reviewed on July 5, 2012. Two of two records reviewed, specifically #'s 3 and 4, did not include documentation to verify that the employees received fire extinguisher training within 3 days of employment.
Employee # 3 was hired on November 26, 2011. The record contained documentation of fire extinguisher and fire / emergency training that was signed by the employee but not dated. Therefore, it was not possible to determine when the training took place.
Employee # 4 was hired on September 13, 2010. The record contained documentation of fire extinguisher and fire / emergency training that was signed by the employee but not dated. Therefore, it was not possible to determine when the training took place.
The findings were confirmed by the Director of Human Resources during the employee record review.
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Plan of Correction
On July 8, 2012, the HR Director reviewed all staff records to ensure that dates for appropriate trainings are reflected, and signed/initialed by the staff members to confirm training within preset timeframe. In addition, to prevent recurrence, the initial orientation/training paperwork has been updated to reflect date requirements on the form to ensure that all records meet appropriate training timing requirements. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon a review of the facility's Policy & Procedures (P&P) Manual and employee records, the facility failed to document that all personnel on all shifts were trained to perform assigned tasks during emergencies as per facility policy.
The findings include:
The P&P Manual was reviewed on July 5, 2012. The facility's policy regarding fire extinguisher and fire / emergency training specifies that all employees are trained within 3 days of employment.
Two employee records requiring documentation of emergency training were reviewed on July 5, 2012. Two of two records reviewed, specifically #'s 3 and 4, did not include documentation to verify that the employees were trained for emergencies within 3 days of employment.
Employee # 3 was hired on November 26, 2011. The record contained documentation of emergency training that was signed by the employee but not dated. Therefore, it was not possible to determine when the training took place.
Employee # 4 was hired on September 13, 2010. The record contained documentation of emergency training that was signed by the employee but not dated. Therefore, it was not possible to determine when the training took place.
The findings were confirmed by the Director of Human Resources during the employee record review.
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Plan of Correction
On July 8, 2012, the HR Director reviewed all staff records to ensure that dates for appropriate trainings are reflected, and signed/initialed by the staff members to confirm training within preset timeframe. In addition, to prevent recurrence, the initial orientation/training paperwork has been updated to reflect date requirements on the form to ensure that all records meet appropriate training timing requirements. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based upon a review of the facility's Policy & Procedure (P&P) Manual and client records, the facility failed to document physical examinations as per its own policy.
The findings include:
The P&P Manual was reviewed on July 5, 2012. The facility's policy regarding physical examinations specifies that all clients must have a physical exam as part of the intake process. The policy permitted clients to utilize a physical exam that was conducted within the past year. However, if no documentation of a prior physical was available upon admission, then the policy specified that the client would have to obtain a physical, at their own expense, within 14 days of admission.
Eight records requiring documentation of a physical exam were reviewed on July 6, 2012. Two of eight records, specifically #'s 1 and 6.5, did not contain documentation of a physical exam that was completed within the past year or within 14 days of admission.
Client # 1 was admitted on May 2, 2012, and was still an active client on the date of inspection. The record did not include documentation of a physical exam.
Client # 6.5 was admitted on April 23, 2012, and was still an active client on the date of inspection. The record did not include documentation of a physical exam.
The findings were confirmed by the Clinical Director during the record review.
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Plan of Correction
Both clients in question were admitted from the same provider, who utilizes an RN to conduct physical examinations. The clinical director contacted the referring provider on July 9, 2012 requesting confirmation on physical status so that he could schedule an additional physical, as needed. The provider responded back to the clinical director after both clients had already left the facility, confirming their physicals were signed electronically and could not be altered.
On July 9, 2012, the clinical director contacted the aftercare coordinator from the provider in question to request a change in paperwork and ensure that all physical examinations are provided by a PA-Certified physician going forward. In addition, to prevent recurrence, the Intake Coordinator was re-trained on July 9, 2012 to review all physical examination submissions to ensure doctor's signature and to avoid admittance of any client who has not received a full physical examination from a physician. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based upon a review of the facility's Policy & Procedures (P&P) Manual and client records, the facility failed to verify that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
The findings include:
As per the P&P Manual, which was reviewed on July 5, 2012, all clients are assigned work therapy as part of their treatment experience.
Eight client records requiring documentation of work therapy were reviewed on July 6, 2012. Seven of eight records, specifically #'s 1, 3, 5, 6.5, 7, 8, and 9, did not include documentation that verified that work completed by the client was an integral part of his treatment plan.
Client # 1 was admitted on May 2, 2012, and was still an active client at the time of the inspection. The record did not include documentation that verified that work completed by the client was an integral part of his individual treatment plan.
Client # 3 was admitted on May 19, 2012, and was still an active client at the time of the inspection. The record did not include documentation that verified that work completed by the client was an integral part of his individual treatment plan.
Client # 5 was admitted on June 12, 2012, and was still an active client at the time of the inspection. The record did not include documentation that verified that work completed by the client was an integral part of his individual treatment plan.
Client # 6.5 was admitted on April 23, 2012, and was still an active client at the time of the inspection. The record did not include documentation that verified that work completed by the client was an integral part of his individual treatment plan.
Client # 7 was admitted on February 2, 2012, and was still an active client at the time of the inspection. The record did not include documentation that verified that work completed by the client was an integral part of his individual treatment plan.
Client # 8 was admitted on February 17, 2012, and was discharged on May 17, 2012. The record did not include documentation that verified that work completed by the client was an integral part of his individual treatment plan.
Client # 9 was admitted on March 21, 2012 and was discharged on May 7, 2012. The record did not include documentation that verified that work completed by the client was an integral part of his individual treatment plan.
The findings were confirmed by the Clinical Director.
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Plan of Correction
On July 18th, during treatment plan reviews, all clinicians were trained on compliance with this portion of the treatment plan by the clinical director. Individuals whose treatment plan did not reflect work therapy documentation have been updated by their counselors to ensure that their treatment plan appropriately reflects treatment given.
During bi-weekly treatment plan reviews, all treatment plans will be reviewed by the clinical team for ongoing compliance with this directive.
To prevent recurrence, all new clinicians will be trained in the 9 dimensions of client treatment planning by the clinical director prior to completion of their first treatment plan. In addition, all charts will be reviewed for compliance by the clinical director on a bi-weekly basis to prevent recurrence. |