INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14-17, 2009 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 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 August 14, 2009.
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Plan of Correction
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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of the agency self reporting staffing form, the employee records and interviews with administrative staff, the facility failed to employ individuals who met all of the requirements for counselor.
The findings included:
During the onsite inspection the records of seven clinical staff were reviewed. Six of these staff were designated as counselors. Employees # 2, 4 and 9 did not have documentation of one year of clinical experience at the time of hire and therefore were not qualified for their designation as counselors . No documentation was presented to demonstrate that the required period of supervision was documented for each unqualified staff as required under 28 Pa. Code Chapter 704 subsection 704.9.
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Plan of Correction
Employees #2 & #4 have been changed to counselor assistants as of 7/27/09. As of this date, there is a plan in place and they receive the appropriate supervision according to 704.9. The plan for each employee is they will receive an hour of supervision and one hour of direct observation. Employee #1 completed this.
Counselor #9 has submitted resignation.
Employee's #2, #4 and #9's previous job descriptions have been resubmitted to the Division for review for further feedback regarding ongoing supervision. As a result, Joe Myers indicated that employee #4 would require supervision under 704.9 until October 1, 2009 and then could be considered a counselor. Employee #2 would require the full six months of supervision under 704.9.
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection conducted on July 17, 2009, the facility failed to ensure that there were no space heaters in use.
The findings included:
During the physical plant inspection of the facility, a space heater was observed on the floor of the office designated as 110 A.
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Plan of Correction
On 7/21/09 staff was reminded during a group staff meeting, by employee #1, that no space heaters could be utilized on the premises. All space heaters have since been removed. As a result of the citation, the safety committee has drafted an administrative policy, which forbids the use of such devices. In addition, all personal electrical devices brought into the agency will be inspected and tagged for approval by the safety committee. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on the physical plant inspection of July 17, 2009, the facility failed to ensure that all fire exits remained unobstructed.
The findings included:
During the physical plant inspection a small group counseling area was noted to contain the second marked exit from the counseling suite. The room was noted to be small in size and it contained a table and a number of chairs. the table and chairs and an additional folding table which was located on the floor next to the exit door were noted to be obstructing egress from the exit.
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Plan of Correction
The Director of Clinic Operations has removed the table in the group room and a smaller table, which does not obstruct the exit, has replaced it. The folding table next to the door has also been removed. These changes occurred 8/6/09.
A sign has been posted that says "Do NOT Obstruct the Exit". Also, Employee #1 reissued a copy of the Fire Safety Policy, SAF03, to staff members on 8/19/09. The agency's internal Safety Committee will do random checks that protocol will be followed.
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709.24(a)(2) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Treatment models utilized by the project.
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Observations
Based on the review of the administrative manuals during the onsite licensing inspection of July 14- 17, 2009, the facility failed to document treatment models and definitions in the agency manual.
The findings included:
During the onsite inspection the agency manuals were reviewed . Treatment models utilized were not documented or defined in the agency manual. Administrative staff were asked to provide the required documentation. The materials presented included syllabus descriptions designed for use by the client population. It was clear from the training staff received that Cognitive Behavioral Therapy was being included as part of the treatment regimen but it was not defined in the agency manual or listed as a treatment model.
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Plan of Correction
The syllabus descriptions of the therapy modalities used have been implemented into policy form by Employee #1 as of 7/14/09. The policies are now part of the agency manual. The therapy modalities added include Rational Emotive Behavioral Therapy and Cognitive Behavioral Therapy. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policy and procedure manual during the onsite licensing inspection of July 14-17, 2009, the written confidentiality policy failed to comply with the requirements of confidentiality laws and regulations at 4 Pa. Code Subsection 255.5; 71 P. S. Subsections 1690.108 and 1690.112 and 42 CFR Part 2, Subparts A through E.
The findings included:
During the onsite inspection the agency policy and procedure manual and HIPAA notification statements were reviewed for compliance with applicable confidentiality law/regulation. The policy failed to correctly address the required laws/regulations as specified below:
Definitions listed on Page 2 of the confidentiality section of the policy and procedure manual defines "records" as "...including but not limited to all written clinical information, observation and report of fiscal documents, relating to past, present or prospective clients". Confidentiality is protected in both written and verbal forms for any individual who is identified as a participant in a D&A program. Federal regulations at 42 CFR Part 2, Subpart B, Subsection 2.12(a) state that, "The restrictions on disclosure in these regulations apply to any information, whether or not recorded, which: (i) Would identify a patient as an alcohol or drug abuser either directly, by reference to other publicly available information, or through verification of such an identification by another person..."
Page 3 of the confidentiality policy and procedure, paragraph 2, stated that " Consideration should be given to advising the facility of the possible detriment to the patient's treatment should the patient be granted access to the information that is released." This contradicts 28 Pa. Code Subsection 709.28(c) which requires an informed and voluntary consent and is inconsistent with 28 Pa. Code Subsection 709.28(c)(2) and 42 CFR Part 2, Subpart C, subsection 2.31(a)(5) which require the facility to list the specific information (how much and what kind) that will be released. If the patient cannot see it, the facility may not release it.
Page 2 of the confidentiality policy and procedure, #3 (ii)- states that information will be released without the clients' written consent in response to emergency medical situations when necessary to prevent serious bodily harm or death. This is inconsistent with state law at 71 P. S. Subsection 1609.108(b) which states "...except that in emergency medical situations where the patient's life is in immediate jeopardy, patient records may be released without the patient's consent to proper medical authorities solely for the purpose of providing medical treatment to the patient..." The facility policy an procedure manual repeats the inaccurate language on page 5 of the confidentiality policy and procedure at #5 (c)- "In emergency medical situations as necessary to prevent serious risk of bodily harm or death and only to the extent necessary for relief of the emergency situation"
Page 5 of the confidentiality policy and procedure manual, section (e) regarding released of information without th client's written consent, states in part that information may be released ... "To the court or Mental Health review officer in the course of commitment proceedings". This is inconsistent with the federal regulations at 42 CFR Part 2, Subpart B, Subsection 2.13 which state in part, "The patient records to which these regulations apply may be disclosed or used only as permitted by these regulations and may not otherwise be disclosed or used in any civil, criminal, administrative, or legislative proceedings conducted by any Federal, State, or local authority...".
Page 7 of the confidentiality policy and procedure, section 8(e) refers to the release of client information based on subpoenas and fails to clarify that this is not sufficient for any information that identifies a client as a participant in drug and alcohol treatment, but that in the Commonwealth of Pennsylvania a court order issued by a judge of the court of common pleas is necessary to remove the restrictions against the release of client information without the client's written consent. This is outlined at 71 P.S. Subsection 1690.108(b) and in the federal regulations at 42 CFR Part 2, Subpart E, Subsection 2.61(a).
HIPAA documentation, notification and clarification to clients did not include the appropriate disclaimers that releases of information permitted by the HIPAA regulations are prohibited by the drug and alcohol confidentiality regulations, specifically in relation to the following facility information sections:
Section A. 2- "To obtain payment for treatment"
Section B. 6 "To avoid harm "
Section B 8 "For workers Compensation "
Section C # 1- Disclosures to Family members, friends or other selected person"
Question II section A - "The right to request limits in uses and disclosures of your health information"
section C- "The Right to see or get a copy of your protected health information"
Section D- "The right to Receive a list of certain disclosures of your health information"
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Plan of Correction
The Confidentiality Policy has been changed by Employee #1 as of 8/3/09. The changes in the definition for records listed on page 2 of the policy now include information that is documented and obtained verbally.
On page 3 the paragraph stating,
" Consideration should be given to advising the facility of the possible detriment to the patient's treatment should the patient be granted access to the information that is released." The information granted has already been approved to be released by the client to the facility by use of a release of information. Otherwise, nothing could be given to the other facility. This paragraph simply states that CJ will advise the facility of any reservations about the information being relayed that would be a detriment to ongoing treatment.
The language regarding release of information in a medical emergency has been changed to reflect, "In response to emergency medical situations where the client's life is in immediate peril, only information pertinent to the relief of the emergency may be released."
This has been changed on both Page2, #3(ii) as well as Page 5, section (e).
On page 5, the statement "To the court or Mental Health Review officer in the course of commitment proceedings" has been removed from the policy.
On page 7, section 8(e) has been corrected to state, "Clients receive notice if their chart has been subpoenaed by the court in the pre-treatment information as well as in Statement of Clients Rights and Responsibilities. If a client chart is subpoenaed then the facility will attempt to obtain a release of information to the court system. Only under court order of a judge of the court of common pleas, will information be disclosed without the use of a release of information."
The following corrections were changed by employee #1 on 8/11/09 regarding HIPPA .
Section A as a whole references is referenced to the Confidentiality Policy. A.2 now specifies that a release of information is necessary to obtain payment for treatment.
Section B. 6 "To Avoid harm" has been removed from the policy.
Section B. 8 specifies with the appropriate consent to release information documented.
Section C. 1 specifies with the appropriate consent to release information documented.
Question II Section A indicates that we will honor their request to limit their PHI, however with the exception of the event that their life is in immediate peril.
Section C. states that we will honor their request to see or get a copy of their protected health information but we may deny if it is in the client's best interests. There is a reference to the Confidentiality Policy as well.
Section D. states that the client has a right to receive a list of the disclosures that have been made with an appropriate release of information documented.
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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 review of client records during the annual onsite licensing inspection of July 14- 17, 2009 the facility failed to document consents to release information which contained the stated purpose for the release if information in each client record.
The findings included:
Eleven client records were reviewed during the inspection. Each client record was required to include documentation of written consents to release information which identified a purpose for the release. Consents to release information forms in client records # 1, 3, 4 and 6 did not include documentation of the purpose for the release of information on each written consent to release information form filed in the the client record.
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Plan of Correction
During an all staff meeting on 7/21/09, D&A staff was retrained on how to complete a release of information by Employee #1. Emphasis was placed on documenting the purpose for the disclosure.
Random chart audits are completed by employee #1 during individual and group supervision. Those found to be erroneous will be returned for correction by the supervisor. |
709.91(a)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but not be limited to:
(1) Criteria for admission.
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Observations
Based on the review of the agency policy and procedure manual during the annual onsite licensing inspection July 14-17, 2009, the facility failed to document criteria for admission which acknowledged limitations on elements of the population which could be served by the project.
The findings included:
The policy and procedure on criteria for admission did not document the limitations on the special populations that could be served by the project nor did the policy describe criteria which included age, sex and geographic restrictions in the criteria for admission.
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Plan of Correction
The admission Policy was changed on 8/3/09, by employee #1 to state the following,
"Consumers admitted into the Drug and Alcohol Department are described in Policy D&A #27 Target Populations and D&A #23 Priority Populations. Consumers admitted to the clinic will be treated based on the clinic's capacity. Those consumers that are non-English speaking will be referred to another facility if at the time CJCMHC does not possess staff that speak the same language. The facility is handicap equipped. If a consumer is deaf, the agency will make arrangements for an interpreter to be present for the sessions. If a consumer were to present actively psychotic, a referral would be make for MH treatment and a referral to be admitted to an inpatient MH facility, if admission requirements are met. All other presenting issues will be handled on an individual basis."
The policies referenced identify age and sex. Geographic restrictions would be encompassed in the statement regarding cases handled on an individual basis.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on the review of documentation in client records during the annual onsite licensing inspection of July 14-17, 2009, the facility failed to document drug and alcohol histories which identified patterns of drug and alcohol use in each record.
The findings included:
Eleven client record were reviewed during the annual onsite licensing inspection . Each client record was required to include documentation of a complete drug and alcohol history. Lengths and patterns of use were not documented in client records # 1, 2, 3, 4, 5, 6 and 9.
Prior treatment episodes were not documented in client records # 1, 2, 4 and 6.
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Plan of Correction
In order to ensure that a complete drug and alcohol history is completed and prior treatment episodes are documented, the intake supervisor has created an intake audit tool. At least two intakes are randomly chosen and audited per week. The tool was created and put into effect on 7/21/09.
Employee #1 also retrained all staff on this aspect during the staff meeting on 7/21/09. The staff was given an overview to demonstrate how this is to be completed comprehensively. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client record documentation during the annual onsite licensing inspection of July 14. 17, 2009, the facility failed to document personal histories which addressed family relationships, employment histories and educational experiences.
The findings included:
Eleven client records were reviewed during the annual licensing inspection. Each client record was required to include documentation of a complete personal history. Client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, and 20 did not include documentation of family interrelationships. Client records # 1, 2, 4 and 6 did not include documentation of work histories but addressed only most recent or current employment. Client records # 2 and 7 were illegible.
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Plan of Correction
In order to ensure that personal history, family interrelationships and work histories are documented and complete, the intake supervisor has created an intake audit tool. At least two intakes are randomly chosen and audited per week. The tool was created and put into effect on 7/21/09.
Employee #1 also retrained all staff on this aspect during the staff meeting on 7/21/09. The staff was given an overview to demonstrate how this is to be completed comprehensively. |
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 client record documentation during the annual onsite licensing inspection of July 14- 17, 2009, the facility failed to document psychosocial evaluations which addressed coping mechanisms, support systems and clinical impressions.
The findings included:
Eleven client records were reviewed during the onsite inspection. Client records # 1, 2, 3, 4, 6, 7, 8, 10 and 11 did not include documentation of coping mechanisms used by each client. Client records # 8 and 9 did include documentation of support systems available to the client. Client records # 1, 3, 5 and 11 did not include documentation of clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation.
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Plan of Correction
In order to ensure that coping mechanisms, support systems and clinical impressions are documented and included in the psychosocial evaluation, the intake supervisor has created an intake audit tool. At least two intakes are randomly chosen and audited per week. The tool was created and put into effect on 7/21/09.
Employee #1 also retrained all staff on this aspect during the staff meeting on 7/21/09. The staff was given an overview to demonstrate how this is to be completed comprehensively along with a template on how to complete.
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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 the review of client records during the annual onsite licensing inspection of July 13- 17, 2009, the facility failed to document type and frequency of services on each treatment plan.
The findings included:
Eleven client records were reviewed during the annual onsite licensing inspection on July 14- 17, 2009. Client records # 1, 2, 3, 4 and 7 did not include documentation of the type and frequency of services each client was to receive as part of their treatment regimen.
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Plan of Correction
In order to ensure that treatment plans are completed correctly, employee #1 has created a sample treatment plan to be used for training purposes. The staff members were retrained during a staff meeting on 7/21/09 on the completion of treatment plans. In addition, an audit tool has been created. Employee #1 will randomly audit charts during individual supervisions as well as have peer chart audits completed in monthly group staff meetings. The tool was created and put into effect on 7/29/09. |
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 the review of client records during the annual onsite licensing inspection of July 13- 17, 2009, the facility failed to document the proposed type of support service in each client record.
The findings included:
Eleven client records were reviewed during the annual onsite licensing inspection. Client records # 1, 3, 4 and 9 did not include documentation of the proposed type of support service on the comprehensive treatment plans.
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Plan of Correction
In order to ensure that treatment plans are completed correctly, employee #1 has created a sample treatment plan to be used for training purposes. The staff members were retrained during a staff meeting on 7/21/09 on the completion of treatment plans. In addition, an audit tool has been created. Employee #1 will randomly audit charts during individual supervisions as well as have peer chart audits completed in monthly group staff meetings. The tool was created and put into effect on 7/29/09. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records during the annual onsite licensing inspection of July 13- 17, 2009 the facility failed to document aftercare plans which included goals with timeframes based on progress made in treatment.
The findings included:
Eleven client records were reviewed during the onsite licensing inspection. One of these was required to include documentation of an aftercare plan. The aftercare plan on file did not include documentation of timeframes for each goal, listing them as "ongoing" and did not formulate goals focused on sustaining and building on the progress achieved during treatment.
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Plan of Correction
In order to ensure that Aftercare Plans are completed in entirety, all staff members were retrained, by employee #1, on the use of the plans during a staff meeting on 7/21/09. The form used has also been redeveloped and there are triggers for timeframes for each goal that is related back to the treatment stay.
Every discharge chart is audited by the Medical Records Department to ensure all components are included. In the occurrence that an aftercare plan is missing, Employee #1 will be notified and the therapist will be asked to complete the missing item. The aftercare plans that are included will be part of the random chart audits completed by Employee #1. |