INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 11, 2011 through July 12, 2011 licensure renewal inspection. The follow-up inspection was conducted on September 12, 2011 through September 13, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Clem-Mar House, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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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 procedures manual, administrative documentation, 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 2010/2011.
The findings include:
The policy and procedure stated that the annual evaluation will be completed by the clinical director by December 15 of each training year. The licensing specialists requested the human resource director to provide a copy of the annual evaluation of the training plan on September 13, 2011. The document was not produced at the time of the inspection.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the July 13, 2011 through July 14, 2011 licensing inspection. The facility's plan of correction submitted on August 12, 2011 and approved on August 19, 2011 stated the following:
" 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 (2011) 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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Plan of Correction
The HRD did complete the 2011-12 training plan. While the prior year's trainings were evaluated at that time to create 2012 plan, written documentation was not.
Written documentation of prior year's training plan was created and completed by the HRD as of 9/26/2011, and will be completed annually going forward on or before 6/30 of each year.
To ensure that the issue does not recur, the HRD will be meeting with the senior leadership team at the end of each fiscal year to review all staff feedback on trainings and create for the year coming. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on licensing specialist observation and staff interview, the facility failed to have the restroom ventilated by exhaust fan or window.
The findings include:
A licensing specialist observed on September 13, 2011 at 1:10pm, that the employee restroom on the first floor of the facility did not have a operative exhaust fan or window for ventilation. The clinical supervisor was interviewed on September 13, 2011 and confirmed the findings.
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Plan of Correction
The venitlation fan's issues were addressed by the resident maintenance technician on 9/13. The final parts for the fan were received and installed on 9/26/2011. To prevent recurrence, additional inspections of downstairs bathroom(s) will be performed daily by the day-shift resident manager on duty. |
705.9 (4) (i) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of residents and staff to a safe location.
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Observations
Based on staff and client interviews, the facility failed to follow their evacuation procedures when it came to transferring clients and staff to a safe location per their policy and procedure.
The findings include:
During staff and client interviews on September 12, 2011 and September 13, 2011 it was discovered that the male clients were evacuated on September 8, 2011 through September 10, 2011 to the female facility. The Edwardsville facility did not follow their evacuation policy and procedure.
The flood plan policy states: " In case of an emergency (and the) flood and evacuation plan is necessary. The following becomes effective. Upon notice of impending flood and notice of the Civil Defense and/or Emergency Management Association, the project director or clinical director will direct the residential manager to initiate the following procedures:
A. Male House: all clients will move furniture, business machines, files and valuables to upstairs offices. This is contingent upon time allowed for evacuation.
B. All clients will immediately pack one small survival bag including -- hygiene kit; two changes of shirts, pants, socks and underwear; one coat, hat, sweater and any personal belongings that will fit in one small bag.
C. The resident manager will count all clients assembled in the great room.
D. The resident manager will then transport 12 clients via the CMH van to the (specified location). The community leader will take charge of the remaining clients in R.M's absence.
E. The resident manager will identify a common area and a common time to meet upon arrival at (the specified location).
F. The resident manager will return to CMH for the remaining van load of clients who will likewise be transported to (specified location).
G. Upon arrival at (specified location), the resident manager will conduct a census count of clients in designated common area.
H. NOTE: resident manager will pack all client medication with medication log book and dispense as prescribed at the evacuation site. In the event of overcrowding at the (specified location), the resident manager will report with all clients to (another specified location).
I. After all clients are secured at the proper evacuation site, the resident manger will attempt to contact the project director at their home telephone number and/or clinical director at their home telephone number to report clients status and follow up instructions or directors designees. Alternate telephone numbers will be furnished to the resident manger if necessary.
J. Upon clearance instructions from E.M.A. personnel to project director and/or clinical director, the resident manager will be given the approval to return the clients to residency at Clem-Mar House.
K. Male House: all furniture, business machines, files and valuables place on second floor will be returned to their point of origin.
L. Normal daily activities will resume at that time."
Staff and client interviews were conducted on September 12 and September 13, 2011. Female clients were interviewed disclosed that the male clients slept at the female facility on September 8 and September 9, 2011. Staff were interviewed as well and confirmed that the male clients did stay at the female facility for two nights and returned to the male facility on September 10, 2011. The staff interviewed confirmed that the facility did not follow their flood evacuation plan. The staff indicated that in the past when the male facility had to be evacuated for flood concerns that the evacuation plan was followed and the clients and staff reported to the (specified location). An interview with the human resource director confirmed that the project director failed to follow their policy and procedure to evacuate the male facility to an emergency response center.
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Plan of Correction
Understanding that this is not part of the Policy & Procedure, and to avoid recurrence of this concern, the P&P has been updated as of 9/26/11 to state "an applicable, approved, evacuation site" rather than the prior, specific, location as both locations listed (primary and contingency) were not confirmed as evacuation shelters at the time of necessary evacuation. The approved evacuation site will be one of those listed on the current listing of approved Red Cross Shelters provided by an ARC representative.
The applicable updates to the Policy and Procedure were implemented by the HRD, and will be followed-through on by the Clinical Director (s) of each site. The Board and its' President approved the changes at the meeting of the BoD on 9/29/2011. The updates to policy and procedure that refer clients to ARC-approved shelter locations (listed in the policy and procedure handbook, as provided by the local red cross office) and provide the necessary contacts, should those shelters not be available.
Contact has been made to the local American Red Cross on 9/26/11, and the shelters were updated on that date. In addition, the HRD will maintain contact with the American Red Cross to be notified of any additional changes to shelter locations so that she can update the P&P manual accordingly. |
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 administrative documentation, 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:
An interview with the human resource director on September 13, 2011 confirmed that a letter of agreement with a licensed hospitals or physician, for 24 hours emergency medical coverage was not updated. This was also confirmed on September 13, 2011 by the office billing clerk.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the July 13, 2011 through July 14, 2011 licensing inspection. The facility's plan of correction submitted on August 12, 2011 and approved on August 19, 2011 stated the following:
"The Office Director Composed, and received, 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."
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Plan of Correction
Several letters have been sent to approved hospital with which prior agreement was reached, with no response. On 10/11/11, additional contact was made with the provider and letter of agreement was sent to the attention of a specific party with which CMH can do followup to ensure receipt and signature on necessary documentation. Expected rec'd by date is 10/28/11.
To ensure that this issue does not recur, all letters of agreement have been placed in order of expiration, and follow-up on necessary agreements will begin 2 months prior to expiration. The facility will also utilize county and local contacts to update contacts, as needed, in the LoG records.
The office manager, who maintains all contracts & agreements will ensure that this is implemented and reviewed. |
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 four of six client records.
The findings include:
Six client records were reviewed on September 13, 2011. A psychosocial evaluation was required in seven of those records, #1, 2, 3, 4, 5 and 6. An interview with the clinical director on September 13, 2011 confirmed the findings.
The psychosocial evaluations in client records # 2 and 3 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records # 2, 3 and 4 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records # 2, 3 and 4 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records # 2, 3 and 4 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records # 2 and 3 did not include an evaluation of the client's attitude towards treatment.
The psychosocial evaluations in client records # 2, 3 and 4 did not include an evaluation of the counselor's conclusion and impression of the client.
Client #1 was admitted on 8/24/11, their psychosocial evaluation was to be completed within 10 days of the clients admission date, September 2, 2011. As of the date of the inspection, the clients psychosocial evaluation was not documented.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the July 11, 2011 through July 12, 2011 licensing inspection. The facility's plan of correction submitted on August 12, 2011 and approved on August 19, 2011 stated the following:
"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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Plan of Correction
After State Auditors left the facility, the clinical director retrained the counselors on the appropriate documentation for client psychosocial evaluations, including detailed assessments of the client's strengths, support systems, negative factors, and how they would relate to/impact the client's treatment.
To prevent recurrence, the clinical director will continue weekly monitoring of client charts. In addition, on 10/11/11, A Clinical Administrator with qualifications to oversee charts, etc., will act as a back up to Clinical Director QA to ensure oversight addresses any deficiencies in client documentation. The Clinical Administrator will review charts on a monthly basis. |
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 September 13, 2011. Aftercare plans were required in client records # 3, 4 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 September 13, 2011 confirmed the findings.
Client #3 was discharged on August 23, 2011 and an aftercare plan was not documented.
Client #4's aftercare plan was completed with no date of completion and the goals were documented but did not document the time frames which is required in the client's aftercare plan.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the July 11, 2011 through July 12, 2011 licensing inspection. The facility's plan of correction submitted on August 12, 2011 and approved on August 22, 2011 stated the following:
"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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Plan of Correction
The aftercare information in CMH Policy & Procedure was updated on 8/1/11, and the Clinical Director updated the information, as it reflects in the client charts, as of 9/15/11. The updated aftercare planning portion of the chart reflects the client's option to decline an aftercare plan, which pulls that notation of decline from client discharge summary.
In addition, the clinical director will review aftercare plans in advance of the client's discharge to ensure appropriate time-frames are documented thoroughly and the client is aware of the next steps in their appropriate level(s) of care.
To prevent recurrence, the detailed information was updated in the Aftercare portion of client charts, and the specific blank charting information has been scanned in to prevent copying of old/outdated materials by the individuals who put together blank charts.
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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 September 13, 2011. Discharge summaries were required in client records # 3, 4 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, discharge summaries will be documented within 7 days after the client is discharged from the program. An interview with facility staff on September 13, 2011 confirmed the findings.
Client #3 was discharged on August 23, 2011 and their discharge summary documented on August 24, 2011 failed to include documentation of the client's the reason for treatment.
Client #4 was discharged on September 2, 2011 and their discharge summary documented on September 2, 2011 failed to include documentation of the client's the reason for treatment.
Client #6 was discharged on August 19, 2011 and their discharge summary documented on July 29, 2011 failed to include documentation of the client's the reason for treatment.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the July 11, 2011 through July 12, 2011 licensing inspection. The facility's plan of correction submitted on August 12, 2011 and approved on August 22, 2011 stated the following:
"On 7/29/2011, the Clinical Directors of each facility amended 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 in-service 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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Plan of Correction
After State Auditors left the facility, the clinical director printed updated Discharge Summary with appropriate updates reflecting "reason for treatment", updating the information in necessary charts.
To prevent recurrence, the detailed information was updated in the Aftercare portion of client charts, and the specific blank charting information has been scanned in to prevent copying of old/outdated materials by the individuals who put together blank charts.
To ensure that the issue will not recur, the documentation has been updated in an electronic format with the intake coordinator to ensure that each "fresh" chart is reflecting new documentation. Prior copies without the appropriate documentation have been destroyed so as not to utilize inappropriately. |