INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 22 - 25, 2013 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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704.12(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 a review of the Staffing Requirements Facility Summary Report form completed by the facility, the facility failed to ensure that staff caseloads remained at or under 35:1.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility was reviewed on July 25, 2013. The form listed one clinical supervisor and one counselor.
Employee #1 has assumed the twenty-two client caseload due to unexpected staffing changes. At the time of the inspection, employee #1 exceeded the 35:1 with a caseload of 77:1.
The findings were reviewed with the Outpatient Director and were not disputed.
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Plan of Correction
Based on unforeseen staffing changes, the 35:1 ratio was not maintained. Effective August 19th a new staff member will start at the facility working 40 hours per week responsible primarily for the remaining caseload currently under employee #1. Additionally, the supervisor will monitor closely the caseload and prepare plan to manage the caseload size to ensure that the ratios are maintained. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document monthly fire drills.
The findings include:
The fire drill record log was reviewed on July 23, 2013. The log was reviewed from July 2012 to June 2013. A fire drill was not documented for November 2012.
The findings were reviewed with the outpatient director and were not disputed.
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Plan of Correction
Monthly fire drills have been conducted since the lapse in November. The facility safety committee ensures that monthly drills occur at the facility and will continue to do so to meet compliance. |
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.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update in two of three client records.
The findings include:
Six client records were reviewed on July 24, 2013. Three client records were required to have a treatment plan update . Per the facility policy, treatment plan updates are required to be completed within 60 days of the comprehensive treatment plan. The facility failed to document a treatment plan update in client records #5 and 6.
Record #5 - The client was admitted on March 14, 2013, and was discharged July 10, 2013. The comprehensive treatment plan was completed on April 19, 2013. A treatment plan update was due by June 19, 2013. The facility failed to document the completion of a treatment plan update.
Record #6 - The client was admitted on April 22, 2013, and was discharged July 12, 2013. The comprehensive treatment plan was completed on May 6, 2013. A treatment plan update was due by July 6, 2013. The facility failed to document the completion of a treatment plan update.
The findings were reviewed with the outpatient director and were not disputed.
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Plan of Correction
Based on unforeseen staffing changes, the treatment updates were not completed in a timely manner. Effective August 19th a new staff member will start at the facility working 40 hours per week responsible primarily for the remaining caseload currently under employee #1. The new counselor will begin ensuring that updates are completed within 60 days of the comprehensive treatment plan. The supervisor will be responsible for caseload monitoring and maintenance should another situation occur in which staffing is an issue. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records during the onsite licensing inspection of July 22 - 25, 2013, the facility failed to document the provision of treatment services consistent with the type and frequency specified in the treatment plan.
The findings included;
Six client records were reviewed on July 24, 2013. Each was required to document the provision of services in accordance with those specified in the treatment plan. Due to unexpected staffing changes, services were not documented as stated in the treatment plans in records # 3, 4, 5 and 6.
Client #3 was admitted to treatment on May 29, 2013. The preliminary treatment plan was completed on May 23, 2013 and documented the type and frequency of treatment as IOP with a minimum of five hours of group and individual per week. There was no documentation available to demonstrate this was provided.
Client #4 was admitted to treatment on April 8, 2013. The treatment plan was completed on April 26, 2013 and documented the type and frequency of treatment as IOP with a minimum of five hours of group and individual per week. There was no documentation available to demonstrate this was provided.
Client #5 was admitted to treatment on March 14, 2013, and was discharged on July 10, 2013. The treatment plan was completed on April 19, 2013 and documented the type and frequency of treatment as weekly individual sessions. There was no documentation available to demonstrate this was provided.
Client #6 was admitted to treatment on April 22, 2013, and was discharged on July 12, 2013. The treatment plan was completed on May 6, 2013 and documented the type and frequency of treatment as weekly individual sessions. There was no documentation available to demonstrate this was provided.
The findings were reviewed with the outpatient director and were not disputed.
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Plan of Correction
Based on unforeseen staffing changes, treatment was not provided according to the individual treatment and rehabilitation plan. Effective August 19th a new staff member will start at the facility working 40 hours per week responsible primarily for the remaining caseload currently under employee #1. The new counselor will provide services according to the individual treatment and rehabilitation plan. The supervisor will be responsible for caseload monitoring and maintenance should another situation occur in which staffing is an issue. Additionally, as regulations permit, staff will be assigned to continue offering treatment according to treatment plan. |
709.92(d) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records during the onsite licensing inspection of July 22 - 25, 2013, the facility failed to provide counseling to a client on a regular and scheduled basis.
The findings included;
Six client records were reviewed on July 24, 2013. Each record was required to document that counseling was provided to a client on a regular and scheduled basis. Due to unexpected staffing changes, this was not provided in records # 3, 4, 5 and 6.
The findings were reviewed with the outpatient director and were not disputed.
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Plan of Correction
Based on unforeseen staffing changes, counseling was not provided to clients on a regular and scheduled basis. Effective August 19th a new staff member will start at the facility working 40 hours per week responsible primarily for the remaining caseload currently under employee #1. The new counselor will begin ensuring that counseling is offered on a regular and scheduled basis for clients. The supervisor will be responsible for caseload monitoring and maintenance should another situation occur in which staffing is an issue. Additionally, as regulations permit, staff will be assigned to continue offering treatment on a regular and scheduled basis. |