INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 15, 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:
|
Plan of Correction
|
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.
|
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 was reviewed from July 1, 2016 through July 1, 2017. Employee #2's employee record only documented 4.5 hours of annual training for the training year reviewed. The findings were reviewed with the facility staff during the licensing inspection.
|
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. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
A review of the June 2017 through April 2018 fire drills was conducted as part of the presubmission process. The facility failed to set off a fire alarm or smoke dectector during the fire drills for the months of June 2017, September 2017, December 2017, March 2018 and April 2018. The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The project will be in full compliance with this standard beginning immediately. Starting June 2018, the staff at this facility will set off the smoke detector during all monthly fire drills. This standard was reviewed during staff meeting on May 17, 2018 and will be reviewed every month by the Project Director to insure the correct completion of the fire drill and fire drill records are conducted and documented to meet this standard. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on a review of seven client records on May 15, 2018, the facility failed to adhered to 42 CFR Part 2 and 4 Pa. Code 255.5(b).4 Pa. Code 255.5(b) states: Restrictions. Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following: (1) Whether the client is or is not in treatment. (2) The prognosis of the client. (3) The nature of the project. (4) A brief description of the progress of the client. (5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse. Client # 3 was admitted on 1/25/18 and was an active client as of the date of the inspection. Client record # 3 contained a consent to release information form dated 5-3-18 to a County Probation Department that allowed for the release of the treatment plan, progress on objectives and attendance. The release of the treatment plan exceeded what is permissible under 4 Pa. Code 255.5(b). Additionally the client record contained a Fax cover sheet dated 5-7-18, indicating that 2 pages were faxed to a County Probation Officer; however, there was no copy of the confirmation sheet and page 2 to verify what had been sent.Client record # 2 was admitted into treatment on November 13, 2017 and was an active client at the time of the inspection. The client record contained a letter dated December 19, 2017, identifying him as a drug and alcohol client; however, the facility was unable to provide documentation as to whom the letter went to and that there was a consent to release information form signed allowing the release of information. Additionally, the client record contained documentation of correspondence with the County Probation office, informing them that the client had used Morphine the prior week. The information released exceeded what is permissible under 4 Pa. Code 255.5(b).The findings were reviewed with facility staff during the licensing inspection.
|
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 to obtain an informed and voluntary consent will be completed during client #3 and 2 next scheduled session. Our facility will obtain an informed and voluntary consent from all clients for the disclosure of information contained in the client record that adhered to 42 CFR Part 2 and 4 PA Code 255.5(b). A copy of all documentation mailed, faxed and/or emailed will be in the client record as well as the date, time and initials of the therapist (or staff personnel) will be documented. To ensure correct completion of an informed and voluntary consent where consent is applicable will be reviewed by the Clinical Supervisor 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. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
|
Observations
Based on a review of seven client records on May 15, 2018, the facility failed to document a client medical history and/or drug and alcohol history in three of seven records reviewed. Client #3 was admitted on 1/25/18 and was still active at the time of the inspection. There was an incomplete medical history documented for this client. Client # 6 was admitted on 9/12/17 and was discharged on 10/24/17. There was no documented medical history or drug and alcohol history for this client.Client #7 was admitted on 4/10/17 and was an active client as of the date of the inspection. There was an incomplete medical history documented for this client and there was no documented drug and alcohol history for this client. The findings were reviewed with facility staff during the licensing inspection.
|
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 timetable for completion of the medical history will begin immediately. The primary therapist for client #3 and client #7 completed and updated the client histories at the clients next scheduled session. To ensure completion of the client's medical history and drug and alcohol history will be reviewed by the Clinical Supervisor 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 also discuss this standard during every mandatory monthly staff meeting. |
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:
|
Observations
Based on a review of seven client records, the facility failed to provide a complete client record, which is to include client related correspondence, client aftercare plans, case consultation notes, and follow-up information in three of seven client records reviewed, specifically client record #s 5, 6 & 7.Client # 6 was admitted on 9/12/17 and was discharged on 10/24/17. The client record had no case consultation notes. Client #7 was admitted on 4/10/17 and was an active client as of the date of the inspection. The client had no case consultation notes.Client # 5 was admitted on 11/21/17 and was discharged on 2/28/18. There was no documented aftercare for this client,nor was there a documented follow-up. The findings were reviewed with facility staff during the licensing inspection.
|
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 therapists at our staff meeting on May 17, 2018.The proper completion and timing of completion client aftercare plans, case consultation notes, and follow-up information 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 documentation in the chart. The primary therapist for client #5 will complete the follow-up (form) information immediately. The Project Director will also discuss this standard during every mandatory monthly staff meeting. |