INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Clem Mar House, Inc was found to not 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(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 the Staffing Requirements Facility Summary Report form (SRFSR) and the personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the Facility Director in employee #2's employee record. Employee #2 was hired as Facility Director on 2/20/2009 and was still in the position as of the date of the onsite inspection. The facility's training year reviewed was for the training year from July 1, 2016 through June 30, 2017. Employee #2's employee record only contained documentation of 4.5 hours of annual training for the training year reviewed. The findings were reviewed with the facility staff during their licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard by June 30, 2019, which is the end of our current training year. By that date the Facility Director will have received 12 training hours as is required by the standard. Employee #2 had failed to complete the required trainings. This employee will seek out & attend trainings throughout the year, which will address the areas set forth by the standard. The Clinical Supervisor and Project Director are responsible for ensuring the corrective action(s) is implemented. In the future, the Clinical Supervisor and Project Director will conduct quarterly reviews of all training hours as well as monthly clinical supervision to ensure that this standard is being complied with. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on 05/14/18 at approximately 2:00 pm, it was observed that the downstairs counseling room had no window treatments, thus allowing unobstructed visual access.It was also observed that the discussion in the upstairs counseling room could be heard from outside the room. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project was in full compliance with this standard by May 18, 2018. The Project Director purchased window treatments and installed in the upstairs counseling area as well as the downstairs counseling room. The project was also in full compliance beginning immediately with all counseling rooms utilizing sound machines so counseling sessions could not be heard outside of the rooms. The Project Director reviewed this standard during staff meeting on May 17, 2018 and advised all staff to utilize their sound machines. The Project Director will conduct checks on a regular basis to make sure that all staff are in compliance with this standard. |
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 a physical plant inspection conducted on 05/14/18 at approximately 2:00 pm, it was observed that the upstairs office bathroom exhaust fan was not operational. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project is in full compliance with this standard on May 31, 20018. During the physical plant inspection which was conducted on May 14, 2018 it was brought to the attention of the Project Director that the exhaust fan was not operational in the upstairs bathroom. The Project Director contacted an electrician in the immediate days after and scheduled to have the exhaust fan fixed and operational. The Project Director will conduct quarterly checks to make sure the exhaust fan in this bathroom is still in working condition. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
During a physical site inspection on May 15, 2018 at approximately 2 pm, it was observed that there was storage in the attic and the basement of the outpatient building. There were not two exits from either the attic nor the basement. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project was in full compliance of this standard by May 18, 2018. The storage (items) that were in the basement and attic were immediately removed. The Project Director reviewed with staff members during staff meeting on May 17, 2018 that no one should access the basement or the attic at any time. The facility is unable to provide two exits in either the attic or the basement, neither are utilized by the facility and/or staff. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection conducted on 5/14/18 at approximately 2:00 pm, it was observed that the attic and basements did not have operational fire extinguishers located in them. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project was in full compliance of this standard by May 18, 2018. The Administrative Assistant contacted the Susquehanna Fire Company and fire extinguishers were installed on May 18, 2018. The Project Director purchased smoke detectors and one was installed in both the attic and the basement by May 18, 2018. The Project Director will make sure that the fire extinguishers are renewed every year. The Project Director will make sure that the smoke detectors are operational. The Project Director reviewed with staff members during staff meeting on May 17, 2018 that no one should access the basement or the attic at any time. |
709.28 (c) 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.
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Observations
Based on a review of five client records on May 14, 2018, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in one of five records reviewed, specifically, client record # 3. Additionally, client record #'s 1 and 2, were missing specific information to be released or the name of the person/organization to whom the disclosure was made to.Client #3 was admitted on 10/2/17 and was an active client as of the date of inspection. There were consents to release information to a Clinton County Judge dated 1/23/18, a Children and Youth Services dated 1/23/18, and a different Children and Youth Services agency dated 11/30/17 for the following information:1. Diagnosis2. Psychosocial History3. Physical4. Consultations 5. Treatment plans6. Progress on objectives7. Discharge summary8. Psychotherapy notes9. Attendance10. Medication Records11. Psychiatric Evaluations(Numbers 2, 3, 4, 5, 6, 7, 8, 10 &11 exceed Pa.Code 255.5(b)).Client # 1 was admitted on 8/1/16 and discharged 2/13/18. There was a consent to release information in the record to Suboxone Services of Centre County, for the purposes of "coordinating services" , however nothing specific was checked off. Another consent to release information was to "rehabs" with no specific rehabilitation facility or address listed. Client #2 was admitted on 11/17/16 and discharged on 3/13/18. There was a blank signed consent to release information dated 11/17/16 in the chart with no name of recipient or what information was given. The findings were reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard was reviewed during our agency staff meeting on May 17, 2018. The proper completion and documentation of the consent to release information and to keep disclosure of client identifying information within the limits established by 4 PA Code 255.5 was obtained for clients #3, 1, and 2 during their next scheduled session. Our facility will obtain an informed and voluntary consent from the client and our facility will keep disclosure of client identifying information within the limits established by 4 PA Code 255.5. The completion and proper completion of the required consent forms, including name of person/agency or organization, date, event, and condition of the consent. To ensure correct completion and completion of all consent forms the Clinical Director and Project Director will verify completion during weekly supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to insure compliance. The Project Director will require all staff to review 4 PA Code 255.5 and will discuss during monthly mandatory staff meetings. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of five client records on May 14, 2018, the facility failed to document a complete psychosocial evaluations in two of five records reviewed. Client # 3 was admitted on 10/2/17 and was an active client as of the date of inspection. Client record #3 was missing pages 8 and 10 through 18 in the psychosocial evaluation. Client #5 was admitted on 12/29/16 and was discharged on 1/25/18. Client record #5 was missing various information in the psychosocial evaluation.The findings were reviewed with facility staff during the licensing inspection. This is a repeat citation. The facility was previously cited for noncompliance with this standard during the June 6, 2017 licensing inspections.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard was reviewed with all counselors during staff meeting on May 17, 2018. The (bio) psychosocial history (evaluation) by our standards is to be completed no later than by the end of the 5th individual counseling session. The completion of all missing pages of the (bio) psychosocial history (evaluation) will be completed during client #3 and 5 next scheduled session. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to insure compliance. Due to this being a repeat citation from our licensing inspection dated 6/7/2017 the Project Director will review this policy with each individual counselor as well as discussed during monthly mandatory staff meetings |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include discharge summaries, progress notes, and follow-up information in client record #'s 1 and 2.Client # 1 was admitted on 8/1/16 and was discharged on 2/13/18. The facility failed to document group progress notes for 8/2/17, 8/8/17, 8/11/17 and 8/15/17. Client #2 was admitted on 11/17/16 and was discharged on 3/13/18. The facility failed to document group progress notes for 6/7/17, 6/13/17, 6/20/17, 6/27/17, 7/11/17, 7/18/17, 8/1/17, 8/22/17, 8/29/17, 9/5/17, 9/19/17, 9/26/17, 10/3/17, and 10/10/17. The facility also failed to document a discharge summary and follow-up.The findings were reviewed with facility staff during the licensing inspections.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard was reviewed with all counselors during our agency staff meeting on May 17, 2018.The proper completion and timing of completion of the client record, which includes (but not limited to) the discharge summary, progress notes and follow-up will begin immediately. This standard and policy will also be reviewed with all therapists by the Clinical Supervisor in individual supervision to assure compliance. In the future all therapists will bring open and closed charts to supervision and the Clinical Supervisor will verify that the therapist has the completed the all client record information including discharge summary, progress notes and follow-up in the chart. The primary therapist for client #1 and client #2 will complete the follow up information immediately. |