INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clearfield-Jefferson Community Mental Health Center, 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 October 18, 2007.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
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.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the counselor caseloads and a conversation with the director on September 25, 2007, it was determined that the caseload for personnel record #2 is 52 clients which exceeds the maximum of 35.
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Plan of Correction
Upon completion of licensing, no further cases were assigned to this particular counselor. As he works between all three of our sites, the Director will monitor more closely caselaod size and advise when maximum is reached. Currently is under the allowed 35. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of the board meeting minutes on September 18, 2007, and an interview with the director on September 18, 2007 and September 19, 2007, the facility failed to provide documentation that the 2007 agency goals and objectives were presented to the board of directors.
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Plan of Correction
Goals and objectives were reviewed with the Board but no documentation could be found. This year's goals and objectives will be reviewed with documentation found in the Board minutes but also via a sign off sheet at that particular meeting. The Director will prepare the goals and objectives as well as the sign off sheet for the Chief Executive Officer. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on an interview with the director on September 18, 2007, it was determined that the facility failed to complete an annual audit for the 2005-2006 year. This was a repeat area of non-compliance as it was an identified issue during the previous licensing inspection.
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Plan of Correction
We have had a very difficult time in the various changes that have taken place within our agency in the last few years. Part of the difficulty is in a contract we have with an auditing firm that cannot meet our deadlines due their size ands workload. As aresult, the 2005-2006 audit has been completed. We are working fervishly to have the 2006-2007 completed in a timely fashion and are looking for at alternative audit firms for future audits. The Controller and Chief Executive Officer will be responsible for assuring this happens. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on a facility physical plant inspection on September 21, 2007 at 9:30 AM, it was determined that the facility failed to provide a posted fee schedule.
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Plan of Correction
A fee schedule was posted immediately following the licensing visit. The Director upon routine visits will assure that the schedule remains posted. |
709.28(c)(3) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a client record review on September 21, 2007, it was determined that the facility failed to provide a relevant purpose for the release of information on consent to release information forms. Three of six client records contained consent to release information forms that did not provide a purpose for the release of information. Refer to client records # 1, 3, 4.
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Plan of Correction
The Director reviewed with all staff findings of inspection at their monthly staff meeting on September 27, 2007. As such a review of confidentiality and releases of information specifically was reviewed. Clerical monitoring and supervisory review will assure compliance. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a client record reviews on September 19, 2007 and a conversation with the director, it was determined that the facility failed to provide the type and frequency of services on the treatment plan in three of the six client records reviewed. Client record #1 is missing both type and frequency. Client record # 3 is missing the type of service. Client record #4 is missing the frequency of services.
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Plan of Correction
In staffing on September 27, 2007, treatment plan procedures were reviewed with all staff. Clerical monitoring and supervisory review will assure type and frequency to be included on all treatment plans. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on client record reviews on September 21, 2007, it was determined that the facility failed to provide supportive services on the treatment plans for three of six client records reviewed. Refer to client records # 3, 4 and 6.
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Plan of Correction
See POC previous |
709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
Based on client record reviews and a conversation with the director on September 21, 2007, it was determined that the facility failed to provide a medication record in the sole applicable client record. Client record #5 is missing the frequency at which the medication is to be taken.
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Plan of Correction
In staffing on September 27, 2007, the Director reviewed medication documentation. All staff were advised to complete information if not gained at the intake. Clerical monitoring and supervisory review will assure that medication information is complete. |
709.93(a)(11) LICENSURE Client records
709.93. 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 on September 21, 2007, it was determined that the facility failed to provide documentation of client follow-up. This was missing in two out of two applicable client records. Refer to client records #5 and 6.
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Plan of Correction
In staffing on September 27, 2007, the Director reviewed follow-up procedures. All staff were present. Clerical monitoring and supervisory review will assure compliance. |