INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2011 through July 12, 2011 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.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records and an interview with the human resource director, the facility failed to insure that the staff person appointed to the facility director position met the experience requirements for the position.
The findings were:
Seven personnel records were reviewed on July 11, 2011. Two records were reviewed to assess the qualifications of the project director and the facility director, #1 and 2. Employee # 2, the facility director, was required to have 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which included supervision of others, direct service and program planning. Employee #2 did not meet the experience requirement, lacking supervision of others and program planning.
An interview with the human resource director on July 12, 2011 confirmed these findings.
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Plan of Correction
This has been corrected by the Human Resources Director on 7/15/11. The Facility director listed on the form was done so incorrectly, and the Facility Director on Record (confirmed with DOH after the date of exit interview) meets state qualifications based on being grandfathered as the facility director prior to DOH changes in March, 1996. All necessary paperwork has been updated by the HRD to prevent recurrence. |
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, the facility failed to document monthly supervisory sessions for each new supervisor for the first six months of employment.
The findings include:
Six personnel records were reviewed on July 11, 2011. A review of employee # 2's personnel and training record indicated that no supervisory notes were documented for the initial six months of employment. Employee #2 was promoted on March 15, 2010 to Clinical Director.
An interview with the human resource director and clinical director on July 12, 2011 confirmed that they were done by the previous Clinical Director. The supervision notes were not presented to the licensing inspector for review during the licensing inspection.
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Plan of Correction
The supervisory notes were in the possession of the prior Assistant Project Director, who did not leave of their own volition. The Clinical Supervisor Acknowledged the signing of these documents, though they were unlocatable in the prior APD's files.
To prevent recurrence, and to meet state compliance requirements, the President/Project Director began monthly, documented, supervision with the clinical supervisor which will be housed in the clinical supervisor's employee file to prevent any future recurrence or loss of data. |
704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on the review of the facility's policy and procedure manual and an interview with the human resource director, the facility failed to document the facility's overall plan for staff development.
The findings include:
The policy and procedure manual was reviewed on July 11, 2011 and July 12, 2011. The policy and procedure manual stated that the overall plan would be completed by the clinical director by November 30th of each training year. An interview with the human resource director on July 12, 2011 confirmed the findings and informed the licensing specialist that the overall plan was not completed.
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Plan of Correction
Prior to the inspection on 7/2011, the records and review for trainings was handled by the office manager, per prior POC's. Due to the need for more intense scrutiny, the HR Director has taken on this role, creating a spreadsheet on 7/26 and double-check process to ensure on a monthly basis that anyone who has not received appropriate trainings will have them completed before the date expected. If the individual is not able to complete their training by the time required, they will be removed from the schedule until such time that training is completed.
The policy & Procedure manual has been edited to reflect the change in training review to June 30th to align with the CMH Fiscal and Training Plan Years. To Prevent recurrence, the review of the prior year's trainings will take place with all staff members and be finalized with supervisors as part of the annual review process that affects pay increases. By aligning all with the fiscal/training year, it will ensure that each is completed in concert with the other. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on the review of the facility's policy and procedure manual and an interview with the human resource director, the facility failed to document the facility's annual evaluation of the overall training plan for training year 2009/2010.
The findings include:
The policy and procedure manual was reviewed on July 11, 2011 and July 12, 2011; there was no documentation of the facility's annual evaluation of the overall training plan for the training year 2009/2010. The policy and procedure manual stated that the annual evaluation will be completed by the clinical director by December 15 of each training year. An interview with the human resource director on July 12, 2011 confirmed the findings and informed the licensing specialist that the annual evaluation was not completed.
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Plan of Correction
Prior to the inspection on 7/2011, the records and review for trainings was handled by the office manager, per prior POC's. Due to the need for more intense scrutiny, the HR Director has taken on this role, creating a spreadsheet on 7/26 and double-check process to ensure on a monthly basis that anyone who has not received appropriate trainings will have them completed before the date expected. If the individual is not able to complete their training by the time required, they will be removed from the schedule until such time that training is completed.
The policy & Procedure manual has been edited to reflect the change in training review to June 30th to align with the CMH Fiscal and Training Plan Years. To Prevent recurrence, the review of the prior year's trainings will take place with all staff members and be finalized with supervisors as part of the annual review process that affects pay increases. By aligning all with the fiscal/training year, it will ensure that each is completed in concert with the other.
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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 of personnel records, staffing requirements facility summary report and a staff interview, the facility failed to ensure that all staff obtained a minimum of 6 hours of training in HIV/AIDS and a least 4 hours related topics within one year of the date of hire for counselors and counselor assistant and within two years of the date of hire date for all other staff.
The findings include:
Six personnel records were reviewed on July 11, 2011. There was no documentation of HIV/AIDS or TB/STD training in two employee records. Of the two, one was to have HIV/AIDS and TB/STD training within the first year of employment and the other one was required to have HIV/AIDS and TB/STD training within the two years of employment.
Employee #3 was hired May 25, 2010 and was required to have HIV/AIDS & TB/STD training by May 25, 2011. There was no documentation of HIV/AIDS & TB/STD training in the employee's record as of July 11, 2011.
Employee #6 was hired June 24, 2009 and was required to have HIV/AIDS & TB/STD training by June 24, 2011. There was no documentation of TB/STD training in the employee's record as of July 11, 2011.
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Plan of Correction
Prior to the inspection on 7/2011, the records and review for trainings was handled by the office manager, per prior POC's. Due to the need for more intense scrutiny, the HR Director has taken on this role, creating a spreadsheet and double-check process to ensure on a monthly basis that anyone who has not received appropriate trainings will have them completed before the date expected. If the individual is not able to complete their training by the time required, they will be removed from the schedule until such time that training is completed.
In addition, The Human Resources Director scheduled a training with an American Red Cross certified trainer to provide necessary TB/STD/HIV training on 7/26/11, bringing all necessary employees up to date
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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 facility staff CPR/first aid certification cards, staffing schedule and an interview with facility staff, the facility failed to ensure that at least one person trained in CPR skills onsite during the project's hours of operation.
The findings include:
The updated CPR/first aid certification cards and staff schedules were reviewed on July 12, 2011. Based on a review of staff schedules and staff CPR/first aid certification cards, the facility did not have any staff trained in these skills on duty for the weekend first shift hours during the following weeks: June 13, 2011 (weekend shift June 18, 2011 and June 19, 2011), June 20, 2011 (weekend shift June 25, 2011 and June 26, 2011), June 27, 2011 (weekend shift July 2, 2011 and July 3, 2011) and July 4, 2011 (weekend shift July 9, 2011 and June 10, 2011), all failed to provide s
An interview with the human resource director on July 12, 2011 stated that the two staff on the weekend shift had their updated CPR certification. The CPR updated certification cards were not presented to the licensing inspector for review during the licensing inspection.
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Plan of Correction
Prior to the inspection on 7/2011, the records and review for trainings was handled by the office manager, per prior POC's. Due to the need for more intense scrutiny, the HR Director has taken on this role, creating a spreadsheet and double-check process to ensure on a monthly basis that anyone who has not received appropriate trainings will have them completed before the date expected. If the individual is not able to complete their training by the time required, they will be removed from the schedule until such time that training is completed.
The HRD has received the appropriate documentation of 1st Aid/CPR certification of the parties in question as of 7/26/11, and to prevent recurrence, going forward any individual ? regardless of whether or not they have attended training ? who does not provide the appropriate proof of certification, will be removed from the schedule until they are able to do so.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records and an interview with the human resource director, the facility failed to ensure and document that the project director completed at least 12 hours of training for the July 1, 2010 through June 31, 2011 training year in one of two personnel record.
The findings include:
Six personnel records were reviewed on July 12, 2011. Two employee records represented the project director and facility director who were required to have obtained 12 hours of training for the July 1, 2010 through June 31, 2011 training year based on the hire dates, #1 and 2. A discussion with the human resource director confirmed that the project director did not obtain the required 12 hours of training for training year July 1, 2010 through June 31, 2011 training year.
Employee #1 was hired November 1, 1994 and was required to have obtained 12 hours of training for the July 1, 2010 through June 31, 2011 training year. Employee #1 only showed 9 hours of training for training year July 1, 2010 through June 31, 2011.
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Plan of Correction
The Human Resources Director confirmed with investigator that the hours of training were completed by the Project Director, but acknowledged that the training certificates provided by the external training team did not reflect the hours on them. The HRD reached out to the training team to obtain amended certificates, though they were not provided by the end of the inspection time frame, confirming with the trainers in question the appropriate hours of training on 7/25/2011.
To prevent recurrence, the HRD will be maintaining all training records going forward, reviewing all necessary training data to ensure that the date, subject matter, and hours of training are listed on all proof-of-training documentation. In addition, if an individual's trainer is unable to provide this information, the training will not count for that training year, leaving the employee to make up the additional hours through other means.
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705.5 (b) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(b) Each shared bedroom shall have at least 60 square feet of floor space per resident measured wall to wall, including space occupied by furniture. When bunk beds are used, each bedroom shall have at least 50 square feet of floor space per resident measured wall to wall. Bunk beds shall afford enough space in between each bed and the ceiling to allow a resident to sit up in bed. Bunk beds shall be equipped with a securely attached ladder capable of supporting a resident. Bunk beds shall be equipped with securely attached railings on each open side and open end of the bunk. The use of bunk beds shall be prohibited in detoxification programs. Each single bedroom shall have at least 70 square feet of floor space per resident measured wall to wall, including space occupied by furniture.
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Observations
Based on a tour of the facility during the physical plant inspection, the facility failed to ensure that bunk beds were equipped with a securely attached railing on each open side of the bunk.
The findings include:
The physical plant tour took place on July 12, 2011 at around 10 am. During the tour of the clients bedrooms the following rooms that had bunk beds were not equipped with securely attached railings, rooms #1, 2, 4, 6 and 7.
The clinical director was interviewed on July 12, 2011 and confirmed the findings.
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Plan of Correction
The Resident Managers on staff purchased bunk bed railings from a major retailer immediately after the exit interview. Due to back order, the final railing arrived and was put into place by 7/17/11.
To prevent recurrence, maintenance of the railings will be RM Responsibility as part of the daily room maintenance checks. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement and an interview with the staff, the facility failed to provide documentation of a written agreement with a licensed hospital or physician, for 24-hour emergency medical coverage.
The findings include:
The letters of agreement were reviewed on July 11, 2011. The only letter of agreement regarding 24- hour emergency medical coverage was signed with a local hospital on March 31, 2007. The agreement stipulated that it was in effect for two years and therefore expired on March 31, 2009. There was no other documentation of a 24- hour emergency medical coverage agreement.
The staff was interviewed on July 11, 2011. It was confirmed at that time that no other documentation of a 24- hour emergency medical coverage was available.
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Plan of Correction
The Office Director Composed, and recieved, a copy of the letter of agreement with the necessary local emergency care location (Hospital) on 7/29/2011. She has also restructured her Letters of agreement by expiration date so as not to experience the same concerns or recurrence in the future. |
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 and an interview with the facility staff, 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 six of six client records.
The findings include:
Six client records were reviewed on July 12, 2011. A psychosocial evaluation was required in six of those records, #1, 2, 3, 4, 5 and 6. An interview with the facility staff on July 12, 2011 confirmed the findings.
Client records #1, 2, 3 and 4 failed to provide documentation of a counselor's impressions and conclusions regarding the client.
Client record #6 lacked an evaluation of the client's negative factors that might inhibit treatment.
Client records #1, 2, 3, 4, 5 and 6 failed to document an evaluation of the client's assets/strengths.
Client records #1, 2, 3, 4, 5 and 6 failed to document an evaluation of the client's support systems.
Client records #1, 2, 3, 4, 5 and 6 failed to document an evaluation of the client's coping mechanisms.
Client records # 1, 2, 3, 4, 5 and 6 failed to document an evaluation of the client's negative factors and how they could inhibit treatment.
Client records #1, 2, 3, 4, 5 and 6 failed to document an evaluation of the client's attitude towards treatment.
Client records # 1, 2, 3, 4, 5 and 6 failed to document an evaluation of the counselor's conclusion and impression of the client.
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Plan of Correction
On July 29, 2011 the clinical director reviewed the appropriate process for filling out the client's evaluation, including the need for detailed review and documentation of the client's support systems, coping mechanisms, negative factors, and counselor's conclusion in regards to the application to the client's treatment within the facility.
To prevent recurrence, the clinical director will complete weekly quality assurance and will be providing an inservice to ensure all counselors from both houses will provide documentation that matches the level of care provided to each client.
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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 two of three discharge records reviewed.
The findings include:
Six client records were reviewed on July 12, 2011. Aftercare plans were required in client records # 4, 5 and 6. 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 July 12, 2011 confirmed the findings.
Client #4 was discharged on January 9, 2011 and an aftercare plan was not documented.
Client #5's aftercare plan was completed on December 21, 2010 and the goals were documented but did not document the time frames which is required in the client's aftercare plan.
Client #6's aftercare plan was completed on November 30, 2010 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
On 8/1/2011, the Human Resources Director updated the policy and procedure handbook to reflect the process of aftercare plans for all clients, stating that all clients must be offered the opportunity for aftercare planning at the time of unplanned discharge (ACA or TD) and documentation must be made by client that they decline.
In the event of an ACA discharge due to client abandonment, an attempt to contact client to provide aftercare opportunities will be documented and, decline date/time should also be listed by the individual making contact.
To prevent recurrence, The Clinical Director will be providing weekly quality assurance checks of all charts to ensure that aftercare plans/attempts are appropriately documented.
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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 three discharge records reviewed.
The findings include:
Six client records were reviewed on July 12, 2011. Discharge summaries were required in client records # 4, 5 and 6. 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 July 12, 2011 confirmed the findings.
Client #4 was discharged on January 9, 2011 the facility failed to document the reason for treatment.
Client #5 was discharged on January 1, 2011 and the discharge summary was documented on December 31, 2010. The facility also failed to document the clients reason for treatment and services offered to the client.
Client #6 was discharged on December 12, 2010 the facility failed to document the reason for treatment
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Plan of Correction
On 7/29/2011, the Clinical Directors of each facility ammended the means of documentation for the Discharge Summary to reflect "reason for treatment".
All counselors were made aware of, and trained to, the correct procedures on that date.
To prevent recurrence, the clinical directors will provide weekly quality assurance of client charts to verify information is documented appropriately. In addition, an inservice will be held by 8/30/11 to retrain ALL counselors on appropriate documentation to reflect the level of care provided for the clients at CMH.
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