INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7, 2011 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 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 and a plan of correction is required.
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Plan of Correction
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709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
Based on a review of the facility policy and procedure manual and a discussion with facility staff during the inspection, the facility failed to identify qualifications for Board members in policy or corporate by laws.
The findings included:
During the onsite inspection of July 5-8, 2011 the facility policy manual and the corporate by laws were reviewed. This review occurred on July 5, 2011. No qualifications for membership on the Board were specified in the By Laws or in written facility policy.
During a dialogue with the Project and Facility Director on July 8, 2011 the Project Director acknowledged that no qualifications were identified. The findings were not disputed.
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Plan of Correction
The project director will notify the Board of the need to adopt amended by-laws that shall include, but not be limited to, two (2) qualifications for Board membership. The project director will recommend, at a minimum, that the following two (2) qualifications be adopted:
1. Board members shall be at least 18 years of age.
2. Board members shall have an interest in mental health and/or substance abuse services.
The Board will meet to vote on these qualifications on September 13, 2011. The project director will immediately ensure that the by-laws are changed to reflect these qualifications after a signed resolution by the Board at that meeting. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative polices and procedures, the facility failed to document the annual update of the written manual delineating project polices and procedures.
The findings include:
The administrative policies and procedures were reviewed on July 5, 2011. The project director failed to document the annual update of the written project policies and procedures
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The findings were reviewed with the Project Director on July 8, 2011 at approximately 3:00 P.M. and were not disputed.
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Plan of Correction
The clinical supervisor has developed a sign-off sheet to be kept in the policy and procedure manual that will demonstrate that the project director has annually reviewed and updated the policies and procedures. The project director will have this completed each year by June 30. The current drug and alcohol policies and procedures will be reviewed by the project director and signed off by September 13, 2011. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on the review of the facility policy and procedure manual and administrative reports and an interview with the Clinical Director, the project failed to document collaboration between the project director and governing body in formulating annual goals and objectives for the July 1, 2011 to June 30, 2012 fiscal year.
The findings included:
The annual onsite licensing inspection was conducted July 5-8, 2011. No documentation was presented to demonstrate that the Project Director and the governing body collaborated on the formulation of goals and objectives for the fiscal year which began on July 1, 2011. The Clinical Supervisor was unable to produce the required documentation.
The findings were reviewed with the Project Director on July 8 , 2011 at approximately 2:45 P.M. and were not disputed.
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Plan of Correction
The project director will develop project goals and objectives and present them to the Board of Directors in June of each year. The project director will present the project goals and objectives for fiscal year 2011-2012 at the next board meeting on September 13, 2011. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of the facility policy and procedure manual and administrative reports and an interview with the Clinical Director, the project failed to document annual goals and objectives for the current fiscal year.
The findings included:
The annual onsite licensing inspection was conducted July 5-8, 2011 at this project. As part of the inspection the facility policy and procedure manual and administrative reports were reviewed.
No documentation was presented to demonstrate that the Project Director and the governing body formulated annual goals and objectives for the fiscal year which began on July 1, 2011. The Clinical Supervisor was unable to produce the required documentation.
The findings were reviewed with the Project Director on July 8 , 2011 at approximately 2:45 P.M. and were not disputed.
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Plan of Correction
The project director will have the Board of Directors sign-off approval of the project goals and objectives at the June board meeting each year. The Board of Directors will sign-off on this year's project goals and objectives for fiscal year 2011-2012 at the next board meeting on September 13, 2011. |
709.26(a)(11) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(11) Employe accidents and safety.
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Observations
Based on a review of the facility policy and procedure manual and the facility safety manual, the project failed to document a policy and procedure for the reporting of unsafe conditions at the facility .
The findings included:
The annual onsite licensing inspection was conducted on July 5-8, 2011. As part of the inspection the facility personnel policies and procedures were reviewed. This regulation requires that the personnel procedures include documentation of how unsafe conditions are to be reported.
The Clinical Supervisor was made aware of the missing policy and procedure on July 5, 2011 and again on July 8, 2011 and was unable to provide documentation of a written policy and procedure which addressed this requirement.
The findings were reviewed with the Project Director on July 8, 2011 and were not disputed.
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Plan of Correction
The intake director/safety committee chair and the clinical supervisor have developed a policy and procedures for employee accidents and safety. The policy and procedure will be presented to the project director and Board of Directors for approval at the September 13, 2011 board meeting. The policy will be distributed to all current employees and will be reviewed with new hires at orientation training during the safety training portion. |
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 the review of the facility policy and procedure manual, the facility failed to document a confidentiality policy that addressed 4 Pa .Code subsection 255.5 correctly and failed to address related confidentiality laws and regulations.
The findings included:
On July 5, 2011 and again on July 8, 2011, the facility policy and procedure on confidentiality was reviewed by Division staff. Drug & Alcohol Policy # 16, page 4, section C, subsections (i), (ii), and (iii) incorrectly state that releases of information can be made without client consent to judges and probation/parole officers. The policy also fails to address 4 Pa. Code subsection 255.5 (a)(6) which specifies limitations on client information which may be released to employers.
In addition, the facility's Drug & Alcohol policy references Mental Health policies found in the facility mental health manual. The specific policies referenced include PRI 04, 15, 20 and 21. Policy PRI 15 Subject: Uses and Disclosures for Treatment, Payment and Healthcare operations, outlines instances in which the facility may use client identifying information (PHI - Personal Health Information) for treatment, payment and healthcare operations. This document does not make it clear that for clients receiving Drug & Alcohol treatment and for any information in mental health records that identifies an individual as a "drug abuser" or a "drug dependent person" as defined at 71 P.S. subsection 1690.102, consent must be obtained before releasing any of this information to anyone except where a judge of the Court of Common Pleas or a higher court has issued a court order to release the information.
The findings were reviewed with the Clinical Supervisor and the Project Director and were not disputed.
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Plan of Correction
The clinical supervisor will revise the confidentiality policy to comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information) and present it to the Board of Directors at the board meeting on September 13, 2011 for approval. Once the policy is approved the clinical supervisor will review and distribute the updated policy at a departmental meeting. All therapists will sign-off that they have received and understand the updated confidentiality policy and the clinical supervisor will keep the sign-off with policy in the policy and procedure manual. As new personnel are hired the confidentiality policy will be reviewed and signed off on as part of the new hire orientation within 7 days of hire. This process is overseen by the clinical supervisor. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to identify the specific information to be disclosed on each consent to release information form in four of nine client records.
The findings included:
Nine client records were reviewed during the onsite inspection on July 7, 2011. The facility failed to identify the specific information to be disclosed on the release forms in four of nine client records.
Client record # 3- This client was admitted on 4/26/2011. A consent to release information form dated 4/26/2011 for a release of information to the client's mother identified the specific information to be released ( as well as the purpose for the release) as "emergency purposes only" but failed to document the specific pieces of information from the client record that would be released to the mother in an emergency. Another finding in this record was that a release of information from the record was made to the warden of the Clearfield County Prison on 7/6/2011 without the consent of the client.
Client record # 6- This client was admitted on 6/9/2011. A consent to release information form dated 6/9/2011 failed to include documentation of the specific information to be released.
Client record # 7- This client was admitted on 3/31/2011. A consent to release information form dated 3/31/2011 for a release of information to a family member listed the specific information to be released ( as well as the purpose of the release) as "emergency purposes only" and failed to include documentation of the specific pieces of information that would be released in the event of an emergency.
Client record # 8- This client was admitted on 6/8/2011. A consent to release information form dated 6/8/2011 for a release of information to a family member listed the specific information to be released (as well as the purpose of the release) as "emergency purposes only" and failed to include documentation of the specific pieces of information that would be released in the event of an emergency.
The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
At a departmental meeting scheduled on Wednesday, July 20, 2011, the clinical supervisor retrained all personnel on properly completely releases of information. The clinical supervisor will meet with the intake personnel by August 3, 2011 and retrain them, as well. Each month the intake director will audit 5 intakes and monitor for the proper completion of the releases of information. If deficiencies are found, the chart will be returned to the appropriate staff for correction. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document individualized treatment plans within the timelines reflected in written facility policy and procedure in 3 of 9 client records reviewed.
The findings included:
At the time of the annual onsite inspection on July 7, 2011 nine client records were reviewed. Each of the records in the sample was required to have a comprehensive, individualized treatment plan documented within 30 days of admission as required by facility policy and procedure.
Client record # 1- This client was admitted on 5/12/11 and was last treated on 7/5/11. No treatment plan was documented in this record at the time of the review on 7/7/11.
Client record # 4- This client was admitted on 5/17/11 and was last treated on 7/5/11. The treatment plan documented in the record was signed off on 6/27/11.
Client record # 7 - This client was admitted on 3/31/11 and was last treated on 7/3/11. No treatment plan was documented in the record at the time of the record review on 7/7/11.
The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
At a departmental meeting scheduled on Wednesday, July 20, 2011, the clinical supervisor reviewed with all personnel the timeframe for completing treatment plans. Each month the clinical supervisor will audit 5 charts and monitor for the timely completion of treatment plans. If deficiencies are found, the timeframe will be addressed again in supervision and the necessary disciplinary action will be taken. |
709.93(a)(5) 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:
(5) Progress notes.
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Observations
Based on the review of client records, the facility failed to document progress notes which included data, assessments and plans relative to the clients stated treatment needs and identified treatment goals in five of nine client records.
The findings included:
During the onsite licensing inspection of July 7 , 2011, nine client records were reviewed. Documentation reflected that progress note forms were formatted with prompts for use of a SOAP format which would have met this requirement if the notes fully addressed each of the SOAP components. The Project Director indicated on 5/8/2011, that the use of this format was discontinued because it is no longer viewed as viable in recent trainings and conferences attended which addressed current trends in the Mental Health field. The Project Director acknowledged that well written progress notes should include all of this information.
Client record # 2 - This client was admitted on 4/16/11 and was last treated on 6/22/11. Progress notes documented in this record were missing a Plan component to establish actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks.
Client record # 3- This client was admitted on 4/26/11 and was last treated on 7/6/11. Progress notes documented in this record were missing a Plan component to establish actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks.
Client record # 5- This client was admitted on 5/10/11 and was last treated on 7/5/11 . Progress notes documented in this record were missing a Plan component to establish actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks.
Client record # 7- This client was admitted on 3/31/11 and was last treated on 7/3/11. Progress notes documented in this record were missing a Plan component to establish actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks.
Client record # 8- This client was admitted on 6/8/11 and was last treated on 7/5/11. Progress notes documented in this record were missing a Plan component to establish actions to be taken in light of the evaluation and indicate the direction of treatment and include action steps, counselor plan(s) and client assignments or tasks.
The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
At a departmental meeting scheduled on Wednesday, July 20, 2011, the clinical supervisor briefly reviewed with all personnel the required information needed in a progress note. At a departmental meeting scheduled on Tuesday, August 2, 2011, the clinical supervisor will retrain all personnel in detail on what is required in a progress note. Each month the clinical supervisor will audit 5 charts and monitor for the proper completion of progress notes. If deficiencies are found, the chart will be returned to the appropriate staff for correction. |