INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 19, 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.
|
Plan of Correction
|
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.
|
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.
|
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)(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.
|
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 are staffed by employees trained in first aid and possessing documentation of current CPR certification.
The findings included:
Two employee records were reviewed during the onsite annual licensing renewal inspection of July 16-20, 2012. Facility staff were asked to provide documentation of all staff who had current CPR certification and first aid training and to provide 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 5:00 PM and 6:00 PM on Tuesdays and 7:00 PM and 8:00 PM on Mondays and Wednesdays.
The findings were reviewed with the Project Director and were not disputed.
|
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 is 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.
|
Observations
Based on the "Staffing Requirements Facility Summary Report", the facility failed to ensure that each counselor maintained a caseload at 35:1 or less. One of one 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 documentation on the form for the counselor demonstrated that employee # 1 is carrying a caseload of 39:1.
The findings were reviewed with the Project Director and were not disputed.
|
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:
|
Observations
Based on the review of employee job descriptions, the facility failed to document the signature of the supervisor on the job descriptions in 1 of 2 employee records.
The findings included:
Two employee records were reviewed on July 17, 2012. Each record was required to include documentation of the employee's and supervisor's signature on the job descriptions. One of two employee records reviewed failed to include documentation of the supervisor's signature on the written job description.
.
Employee record #2- This employee was hired on 11/7/11. There was no documentation of the supervisor's signature on the employee's job description.
The findings were reviewed with the Project Director and were not disputed.
|
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(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records and the facility policy manual, the facility failed to document individualized treatment plan updates within the timeframe specified in written facility policy in one of three client records.
The findings included:
Five client records were reviewed on July 18-20, 2012. Three of these were due to include documentation of treatment updates. According to facility policy each client record is required to include documentation of treatment plan updates every sixty days. One of three client records failed to include documentation of treatment plan updates within the timeframe specified in facility policy and procedure.
Client record # 1 - This client was admitted on 9/15/11 and was last treated on 7/12/12. The preliminary treatment plan was documented on 9/15/11. The comprehensive treatment plan was documented on 10/13/11. Treatment plan updates were documented on 12/15/11 and 2/17/12.
The findings were reviewed with the Project Director and were not disputed.
.
|
Plan of Correction
A database has been developed for the D&A Director to monitor accurate and timely submission of treatment plans. Staff will be re-trained in the timely submission of treatment plans during the D&A staff meeting dated August 10, 2012. Timeliness will be monitored through monthly chart audits and weekly supervisions with therapists. |
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.
|
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 client records.
The findings included:
Five client records were reviewed on July 19, 2012. Two of the 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 # 5- This client was admitted on 4/23/11 and was last treated on 2/28/12. The aftercare plan 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, and healthy leisure pursuits during treatment. None of the goals that were discussed with the client during treatment were reflected on the after care plan.
Client record # 6- The client was admitted on 9/22/11 and last treated on 3/2/12. The aftercare failed to include goals designed to build on the progress achieved during treatment. The client worked on abstinence, improved coping skills, and learning of personal stressors and how to deal with them during treatment. These goals were not reflected in the aftercare plan documentation.
The findings were reviewed with the Project Director and were not disputed.
|
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. |
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.
|
Observations
Based on a review of client records and the facility policy manual, the facility failed to document follow up within timeframes specified in facility policy in three of three client records.
The findings included:
Five client records were reviewed on July 18-20, 2012. Three of these were records of discharged clients where a follow attempt was due to be documented. Three of three client records failed to include documentation of follow up attempts within the timeframe specified in facility policy and procedure. Facility policy and procedure required that follow up be documented at 30 days and 6 months post discharge.
Client record # 4- This client was admitted on 4/26/12 and discharged on 5/31/12. There was no documentation of a follow up attempt.
Client record # 5- This client was admitted 4/23/11 and discharged 2/28/12. There was no documentation of a follow up attempt.
Client record # 6- This client was admitted 9/22/11 and discharged on 3/2/12. Follow up was not documented in this record until 4/11/12.
The findings were reviewed with the Project Director and were not disputed.
|
Plan of Correction
The D&A Director has updated the administrative process in regards to the agencies follow-up policy. Administrative support staff will document in the client's record when the follow up was mailed. Additionally administrative support staff will date stamp a copy of the correspondence and file in the client record. |