INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 19, 2023 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted during a complaint investigation on 12/19/23, it was observed that the facility failed to ensure the safety and well-being of clients, staff and visitors. An outlet cover was missing from one electrical outlet in the small group room.
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Plan of Correction
Maintenance staff within the facility installed an outlet cover on Friday 12/29/23. The Project Director inspected to ensure compliance on 01/02/24.
During regular, weekly facility inspections the Project Director or designated representatives shall ensure that the Clem-Mar House maintains continued compliance with Chapter 705.2. Building exterior and grounds. The residential facility shall: (2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards, including all outlets and covers.
If any safety discrepancies are noted, the Project Director will work the facility maintenance staff, or outside agencies, to immediately repair any documented issues within a timely manner.
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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 on client chart reviews conducted on December 19, 2023, the facility failed to provide a complete client record which is to include verification that work done by the client at the facility is an integral part of the treatment and rehabilitation plan in 2 of 6 charts reviewed. Client # 1 was admitted on 9/19/23 and was still an active client at the time of the investigation. According to the Client Program Guidelines, weekly chores are assigned by staff and rotate based on seniority. Treatment plans dated 10/27/23 and 11/24/23 were missing documentation of these chores.Client # 2 was admitted on 9/23/23 and was still an active client at the time of the investigation. According to the Client Program Guidelines, weekly chores are assigned by staff and rotate based on seniority. Treatment plans dated 11/8/23 and 12/7/23 were missing documentation of these chores.
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Plan of Correction
The Project Director will review, and update, if necessary, the project's existing policies regarding Chapter 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.
On the afternoon of 12/19/23 the Project Director met with the Clinical Team to review Chapter 709.53 including work therapy and its documentation within the Comprehensive Treatment Plan and Treatment Plan Updates. The Clinical Team Lead will ensure that all staff members receive in-house training in facility policies and procedures regarding client records as well as training in facility documentation policies. This will take place by January 12th and will be overseen by the Project Director. The Clinical Team Led will continue to act as the quality assurance monitor. This team member will review all closed client charts as well as perform ongoing reviews of open client charts to ensure compliance with all regulations and facility documentation standards. This will include, but is not limited to, ensuring that all client charts include worth therapy, chores, and life skills as an area of each treatment plan and update. Review of active charts takes place every other Thursday as a clinical team beginning 12/14/23.
All future treatment plan updates for both Client # 1 and Client # 2 will contain documentation of chores as an integral part of life skills.
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