INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 7, 2011 licensure renewal inspection. The follow-up inspection was conducted on January 4-5, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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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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 four of seven client records reviewed.
The findings included:
At the time of the plan of correction onsite inspection on January 5, 2012, eleven client records were reviewed. Four of the eleven client records were not required to have a comprehensive, individualized treatment plan documented. Seven of the eleven client records were required to have a comprehensive, individualized treatment plan documented within 30 days of admission as required by facility policy and procedure.
Client record # 2- This client was admitted on 10/24/11. The treatment plan was due 11/24/2011 and was documented on 11/28/2011. This is longer than the 30 day time frame.
Client record # 4- This client was admitted on 8/6/11. The treatment plan was due 9/6/2011. No treatment plan was documented in the record at the time of the record review on 1/5/2012.
Client record # 5 - This client was admitted on 8/16/11. The treatment plan was due 9/16/2011. A copy of the 9/16/2011 plan was signed by the counselor on 11/21/11 with a statement "reprinted copy".
Client record # 10- This client was admitted on 10/13/11. The treatment plan was due 11/13/2011 and was documented on 11/22/2011. This is longer than the 30 day time frame.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
At a departmental meeting dated January 25th, the departmental supervisor will review with all counseling personnel the timeframe for completing treatment plans according to the Department of Health Chapter 709, subchapter 709.92 and CJ-CMHC departmental policy D&A 13. A training plan and monitoring schedule will be implemented for each counselor at their scheduled supervision to ensure timely completion. Each month the D&A director will randomly audit charts for each D&A therapist and monitor for the proper completion of the treatment plans. Additionally a database is being developed that will alert staff of due dates for treatment plans to further ensure timely completion. If deficiencies are found, the chart will be returned to the appropriate staff for correction and appropriate internal compliance reports will be filed. |
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 six of eleven client records.
The findings included:
At the time of the plan of correction onsite inspection on January 5, 2012, eleven client records were reviewed. Eleven client records were required to include documentation of progress notes which included data, assessments and plans relative to the clients stated treatment needs and identified treatment goals.
Client record # 3- This client was admitted on 10/13/11. 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 8/16/11. 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 # 6 - This client was admitted on 6/24/11. 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 6/26/11. 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 # 10- This client was admitted on 10/13/11. 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 # 11- This client was admitted on 7/26/11. 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 facility director and were not disputed.
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Plan of Correction
At a departmental meeting dated January 25th, the departmental supervisor will review with all counseling personnel how to properly formulate progress notes utilizing the plan portion of the progress note according to the Department of Health Chapter 709, subchapter 709.93 and CJ-CMHC department policy D&A3. A monitoring schedule will be implemented for each counselor at their scheduled supervision to ensure proper completion of progress note documentation. Each month the D&A director will randomly audit charts for each D&A therapist and monitor for the proper completion of the progress notes. If deficiencies are found, additional training will be implemented for the individual staff and appropriate compliance reports will be filed. |