INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 16-20, 2012 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.
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on the review of the facility policy and procedure manual, the project director failed to document an annual evaluation of the overall training plan for the 2011-12 training year done by the Project Director and containing evaluative content .
The findings included:
The policy manual was reviewed on July 16 and 17, 2012. The facility policy manual identified the Project Director Director as the person responsible for completing the annual evaluation.. The annual evaluation was completed by the Clinical Supervisor. The annual evaluation provided for review was a summary of the 2011-2012 training year and failed to include documentation of evaluative content such as whether or not the training plan met the identified training needs for the prior training year.
The findings were reviewed with the Project Director and Clinical Supervisor and were not disputed.
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Plan of Correction
The D&A policy #26 has been changed to reflect that the D&A Director will complete the annual evaluation of the training plan as stipulated in 704.11(a)(4). This policy will be presented by the Project Director to the Board for approval at the September board meeting. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of employee records, the facility failed to ensure that each employee completed the mandatory communicable disease training within the required timeframe. Two of three clinical staff records failed to include documentation of TB/STD and other health related topics training within the first year of employment.
The findings included:
The training records were reviewed on July 17 and 18, 2012. Employee records # 5 and 6 did not include documentation of 4 hours of TB/STD and other health related topics training.
Employee record # 5- This employee was hired on 12/16/10. There was no documentation of 4 hours of TB/STD training.
Employee record # 6- This employee was hired on 2/17/11. There was no documentation of 4 hours of TB/STD training.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
The D&A Director has scheduled a TB/STD training in-house utilizing the DOH curriculum on this topic. The training will be completed by October 20 to allow for adequate time for the trainer to prepare. All new hires will be scheduled by the D&A Director to attend the BDAP training offered within the first year of employment. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of employee training records and staff schedules, the facility failed to document current CPR coverage for a sufficient number of employees to ensure that all hours of operation were staffed by employees trained in first aid and currently certified in CPR.
The findings included:
Nine employee records were reviewed on July 16-20, 2012. Facility staff was asked to provide documentation of all staff who had current CPR certification and first aid training as well as staff schedules. Subsequent to the review of these documents, it was determined that there were no staff with current CPR coverage between the hours of 7:30 AM to 8:00 AM, Monday through Friday or from 7:00 PM to 8:00 PM on Mondays and Wednesdays.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
The D&A Director has scheduled a training to ensure that applicable staff within the system is trained by 9/15/12 to ensure adequate coverage during all hours of operation. Until these trainings are secured staff schedules will be adjusted by the Director to ensure that a sufficient number of trained staff are on site during hours of operation. Training will occur annually as scheduled by the D&A Director to ensure staff remain certified and become certified within 6 months of employment for new hires. |
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 the "Staffing Requirements Facility Summary Report" completed by facility, the facility failed to ensure that each counselor maintained a client to counselor caseload at 35:1 or less. One of three clinical staff had a caseload which exceeded the 35:1 caseload limitation.
The findings included:
The "Staffing Requirements Facility Summary Report" was reviewed on July 16, 2012. The confirmed that employee # 5 was carrying a caseload of 39:1.
The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
The D&A Director will monitor individual therapist caseload weekly to ensure that caseload sizes do not exceed the 35 active FTE limit. The D&A Director will assess the need for additional staff capacity based on these weekly assessments and work with the Human Resource Director to hire additional staff as needed. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on the review of employee job descriptions, the facility failed to document the signature of the supervisor on each job description in 6 of 7 applicable employee records.
The findings included:
Nine employee records were reviewed on July 17, 2012. Each record was required to have documentation that the employee and their supervisor signed off on the written job description for each employee. Six of seven employee records reviewed failed to document the supervisor's signature on the written job description.
Employee record #1- This employee was hired on 6/5/98 and has held her current position in the D&A program since February 2007. There was no documentation of the supervisor's signature documented on the employee's job description.
Employee record #2- This employee was hired on 8/4/03 and has held her current position in the D&A program since February 2007. There was no documentation of the supervisor's signature documented on the employee's job description.
Employee record # 3- This employee was hired on 1/5/12. There was no documentation of the supervisor's signature documented on the employee's job description.
Employee record # 4- This employee was hired on 6/29/10 and has held her current position in the D&A program since 1-5-12. There was no documentation of the supervisor's signature documented on the employee's job description.
Employee record # 6- This employee was hired on 12/16/10. There was no documentation of the supervisor's signature documented on the employee's job description.
Employee record # 7- This employee was hired on 3/13/12. There was no documentation of the supervisor's signature documented on the employee's job description.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
All job descriptions will be signed by employee and supervisor by September 1, 2012. Thereafter all job descriptions will be signed upon hire by employee and supervisor. |
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 a review of client records and the facility policy manual, the facility failed to document proposed support services on treatment plans documented in five of thirteen client records.
The findings included:
Thirteen client records were reviewed on July 18-20, 2012. Treatment plans were documented in twelve of thirteen client records. Five of the twelve treatment plans documented in the client records failed to include the proposed type of support services.
Client record # 2 - This client was admitted on 10/11/11 and was last treated on 6/22/12. The treatment plan was completed on 11/10/11. Proposed support services to be offered to the client were not documented on the treatment plan.
Client record # 3 - This client was admitted on 5/11/12 and was last treated on 7/11/12. The treatment plan was completed on 6/7/12. Proposed support services to be offered to the client were not documented on the treatment plan.
Client record # 7 - This client was admitted on 4/4/12 and was last treated on 7/6/12. The treatment plan was completed on 5/9/12. Proposed support services to be offered to the client were not documented on the treatment plan.
Client record # 8 - This client was admitted on 3/21/12 and was last treated on 7/9/12. The treatment plan was completed on 4/20/12. Proposed support services to be offered to the client were not documented on the treatment plan.
Client record # 11 - This client was admitted on 2/6/12 and was last treated on 4/3/12. The treatment plan was completed on 3/6/12. Proposed support services to be offered to the client were not documented on the treatment plan.
The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
During the August 10, 2012 staff meeting, the D&A Director will train the D&A staff comprehensively on the approved proposed supports to be utilized in documentation. Furthermore, the D&A Director will conduct monthly chart audits and weekly supervision with therapists to ensure that proper supports are listed. |
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 a review of client records and the facility policy manual, the facility failed to document an aftercare plan which documented goals focused on sustaining and building on the progress achieved during treatment in two of two applicable records.
The findings included:
Thirteen client records were reviewed on July 18-20, 2012. Two of thirteen client records were those of clients who had been successfully discharged. Two of two client records failed to include documentation of aftercare plans with goals which focused on sustaining and building on progress achieved during treatment. .
Client record # 10- This client was admitted on 1/12/11 and was last treated on 57/12. The aftercare plan documented at discharge in the record failed to include documentation of goals which built on progress the client made in treatment. The client worked on areas related to relationships, coping skills , healthy leisure pursuits ,etc. during treatment. None of the goals that were discussed with the client during treatment were reflected on the after care plan.
Client record # 11- The client was admitted on 2/6/12 and last treated on 4/3/12. The aftercare documented at discharge failed to include goals designed to build on the progress achieved during treatment. The client worked on abstinence, improved coping skills , learning personal stressors and how to deal with them .etc. during treatment . These goals were not reflected in the aftercare plan documentation.
The findings were reviewed with the Project director and were not disputed.
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Plan of Correction
During the August 10, 2012 D&A staff meeting, the D&A Director will re-train the staff in aftercare planning to ensure that aftercare plans are written to sustain and build upon progress achieved in treatment. Furthermore, the D&A Director will conduct monthly chart audits and weekly supervision with therapists will to ensure that aftercare plans are written to standard. |