INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection regarding the plans of correction for the August 25 through 27, 2008 licensure renewal inspection. The follow-up inspection was conducted on December 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the 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 and a plan of correction is due on February 13, 2009.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
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:
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Observations
Based on a review of the agency policy manual the facility failed to document a policy and procedure which addressed the staff development program.
The findings include:
Documentation of a staff development policy was presented at the time of the onsite inspection of December 22, 2008. The content of the policy language addressed an individual training plan procedure rather than the comprehensive staff development program.
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Plan of Correction
The policy was amended to include the staff development plan being created each May for the upcoming fiscal year that encompasses all applicable agency personnel and internal annual training schedule. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel and training records, the facility failed to document an individual training plan in one of five employee records.
The findings include:
There was no documentation of an individual training plan in employee record # 1 during the plan of correction follow up inspection conducted on December 22, 2008.
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Plan of Correction
An individual training record was created on 12/23/08 upon completion of inspection by the Dept. Director. All training plans will be reviewed and updated annually at the beginning of the fiscal year by each employee and Director. |
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 counselor caseloads as documented on client lists generated by the agency, and the self reporting form provided by the Division, the facility failed to maintain caseloads at or below the 35:1 limit.
The findings include:
During the plan of correction follow up inspection conducted on December 22, 2008, employees # 3 and 4 were carrying caseloads of 48 clients each.
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Plan of Correction
Case loads have been reviewed by the Dept. Director and cases have been discharged or transferred. The agency is also hiring new personnel so that caseloads will be more appropriately distributed. The Dept. Director will evaluate intakes, current caseloads and discharges to ensure that clinicians are not being assigned cases above their limit. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative materials and the annual audit presented during the onsite plan of correction follow up inspection of 12/22/08, the facility failed to document a complete fiscal audit.
The findings included:
Documentation of an audit which was completed on 11/26/08 by McCall Scanlon & Tice, LLC for the fiscal year ended June 30 , 2008 was presented during the inspection. The audit did not document the opinion of the accountant which would confirm that an audit took place and the outcome of the audit.
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Plan of Correction
An audit was completed on 11/26/08 by McCall, Scanlon & Tice. This audit did not express an opinion on the accounts receivable balance as of 6/30/07 and consequently the cash flow statement. While no opinion was rendered on the accounts receivables for the fiscal year, an opinion was rendered on the rest of the accounts and subsequent accounts receivable will be verifiable and have an opinion rendered in future audits.
CJCMHC will ensure that future audits will be made available to auditors at yearly inspection and contain the required information. |
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 a review of the facility manual and client records during the onsite plan of correction follow up inspection of 12/22/08, the facility failed to document a policy which was consistent with the requirements of 4 Pa. Code subsection 255.5.
The findings included:
Documentation of the revised policy and procedure on confidentiality of client records was presented during the inspection. There were instances of incorrect, unclear or ambiguous language in the documents presented . The specific issues noted are as follows;
Page 2-3, Section 2 stated that " Upon receipt of a properly executed authorization of release document, the minimum amount of additional information to establish the claims for which reimbursement is sought may be released". The term "minimum" lacks sufficient specificity to identify what information may be released and fails to ensure that the limitations imposed at 4 Pa. Code Subsection 255.5(b) will be adhered to.
Page 3, Section 3(vi) stated that release without client consent is appropriate for "...research or other activities authorized by the Chief Executive Officer". The approval for research, as specified at 4 Pa. Code Subsection 255.7(a)(3), requires that the Director of the Bureau of Drug and Alcohol Programs review and approve the plan to protect client confidentiality before any such research in Pennsylvania begins. The current policy and procedure does not recognize this portion of the Pennsylvania code.
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Plan of Correction
(Page 2-3)The Confidentiality Policy has been amended to include compliance with 4 Pa. Code Subsection 255.5(b) in regards to the five allowable pieces of information to be released.
(Page 3)The policy has been amended to include approval from the Director of Drug and Alcohol Programs prior to research being conducted according to 4 Pa. Code Subsection 255.7(a)(3) |
709.28(c) 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:
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Observations
Original citation from 08/27/2008 Licensing inspection:
Based on a review of five client records on August 26, 2008, the facility failed to provide an informed consent in two of the five client records where required.
Finding:
The facility did not indicate the specific information to be disclosed on the release of information form in client record #1. The facility included a misfiled treatment plan in another clients' record in client record #1. The facility did not include a release of information form for the funding source in client record #4.
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Plan of Correction
#1 Release of information procedures were reviewed at staffing on 1/23/09. Release has been obtained in correct manner. The misfiled treatment plan has been removed and a compliance report was made to agency compliance officer.
#4 Client's signature was obtained. Staff was informed at monthly staffing on 1/23/09 of renewal procedures. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records during the onsite follow up licensing inspection of 12/22/08, the facility failed to document type and frequency of services on each treatment plan in three of five client records.
The findings include:
Five client records were reviewed during the onsite plan of correction follow up inspection of December 22, 2008. The type of services to be offered to the client was not documented on treatment plans found in client records # 4 and 5. The frequency of services to be offered to the client was not documented in client record # 2.
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Plan of Correction
The formulation of treatment planning was discussed with all staff and they were retrained on 1/23/09 at monthly staffing by the Dept. Director. Cases will be audited regularly for such issues by the Dept. Director and Clinical Superviors. |