INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25 -29, 2008 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 and a plan of correction is due on September 30, 2008.
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Plan of Correction
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704.1-704.2(a) LICENSURE Staffing Compliance Plan
CHAPTER 704. STAFFING REQUIREMENTS FOR DRUG AND ALCOHOL TREATMENT ACTIVITIES
704.1. Scope.
This chapter applies to staff persons employed by drug and alcohol treatment facilities which are licensed or approved under Chapters 157, 709 and 711 (relating to drug and alcohol services; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility) with the exception of staff persons employed in intake, evaluation and referral facilities as delineated in Chapter 709, Subchapter D (relating to standards for intake, evaluation and referral activities) and Chapter 711, Subchapter C (relating to standards for intake, evaluation and referral activities). Staff persons shall possess the qualifications set forth in this chapter and shall also participate in training as required in this chapter.
704.2. Compliance plan.
(a) The project's governing body shall approve a written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Observations
Based on a review of the project policy and procedures, the facility failed to provide documentation of the written compliance plan to insure that the staff persons affected by this chapter meet the appropriate educational and experiential qualifications and receive training as stipulated in this chapter.
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Finding:
The project director was unable to present the compliance plan at the time of the survey. The previous policy and procedure manual could not be located.
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Plan of Correction
A compliance statement that ensures that all staff shall possess all required qualifications as outlined in 704.2 was developed by the Project Director and reviewed and voted on by the CJCMHC board of directors. |
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of the project policy and procedures, the facility was not able to provide the policy addressing the recruitment and hiring of staff appropriate to the population.
Finding:
The project director was unable to provide the policy and procedure. The previous policy and procedure manual could not be located.
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Plan of Correction
CJ CMHC personnel policy #1, which addresses hiring practices, was updated by the H.R. Director to include a statement that it will be the practice of CJ CMHC to recruit & hire staff persons who are appropriate to the population served. |
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 project policy and procedures, the facility failed to provide a complete policy and procedure on the staff development program.
Finding:
The facility did not include time frames for the assessment of staff training needs, completion of the overall training plan and completion of the evaluation of the previous year's training plan. In addition, there was no indication of who, by job title, was responsible for completing these components and how it was to be documented.
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Plan of Correction
The staff development policy to address staff development within the D&A department at CJ CMHC has been updated by the Project Director. The policy reflects an initial assessment of staff training needs within the first five days of employment and then each spring the Program Director will do an update annual assessment of staff training needs. In addition, at this time, the department as a whole will be assessed for the prior years progress on the training plan and a overall training plan will be developed for the upcoming year and reviewed with the board at the regularly scheduled May board meeting |
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 four personnel and training records on August 26, 2008, the facility failed to document individual training plans in three of four records where required.
Finding:
The facility did not document an individual training plan in training records #2, 3 and 4.
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Plan of Correction
Individual training plans were completed for records #2, 3, and 4. Additionally, all staff in the D&A department at CJ CMHC has completed current individual training plans. Furthermore, it will be the practice of CJ CMHC and the responsibility of the Project Director from this point on to ensure that each staff has an individual training plan completed within 5 days of hire and reevaluated each May for the upcoming training year. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of three personnel and training records on August 26, 2008, the facility failed to provide documentation of the TB/STD training in two of the three records where due.
Finding:
The facility did not document TB/STD training in personnel training records #2 and 3.
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Plan of Correction
Each staff person with the D&A department in need of TB/STD training, have been scheduled to attend BDAP training on 10-16-08 by the Project Director. Documentation of communicable disease training will be placed in each individual's training record upon completion. Additionally, all other D&A staff will receive the required AIDS/HIV training within timeframes identified within chapter 704.11 and training will be documented appropriately. |
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 counselor caseloads on August 29, 2008, the facility failed to keep client to counselor caseloads at or below 35:1.
Finding:
The client to counselor caseload for employee # 4 was over the 35:1 limitation.
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Plan of Correction
All D&A caseloads have been reduced, with the addition of new staff, to comply with the 35:1 ratio as identified in 704.12. CJ CMHC Project Director will ensure proper staffing patterns in the future to maintain the 35:1 ratio. |
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 logs on August 25, 2008, the facility failed to provide documentation of monthly fire drills for the last twelve months.
Finding:
The facility did not document fire drills for May 2008 and June 2008. The last fire drill documented was in July 2008.
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Plan of Correction
Fire drills were run at each site for August and September 2008 and CJ CMHC Project Director will ensure that monthly unannounced fire drills are ran at each site from this time on. Each individual fire drill is documented and recorded in the fire drill log. |
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 a review of the administrative information on August 26, 2008, the facility failed to complete the annual audit for 2006-2007 for more than six months from the end of the fiscal year. The annual audit was not completed within a reasonable period of time.
Finding:
The facility did not complete the annual audit for 2006-2007 for more than six months from the end of the facility's fiscal year.
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Plan of Correction
The 2007-2008 audit will be completed within six months from the end of the fiscal year by the CFO. New auditors have been identified. The field work for the 2007-2008 audit has commenced. |
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 project policy and procedures on August 25, 2008, the facility failed to provide a complete policy and procedure on 4 Pa. Code subsection 255.5.
Finding:
The confidentiality policy and procedure was incomplete and did not address 4 Pa. Code subsection 255.5(a)(6). The confidentiality policy and procedure failed to address all components of 4 Pa. Code subsection 255.5(b). The written policy and procedure failed to address the release of client identifying information without the client's written consent.
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Plan of Correction
The agency policy covering D&A confidentiality was updated by the Project Director to include information from 4 Pa. Code subsection 255.5b to include release of client identifying information without the client's written consent. |
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
Based on a review of seven client records on August 28 and 29, 2008, the facility failed to provide an informed consent to release information in one of seven records where required.
Finding:
The facility did not complete a consent to release information form for a release of information to a funding source in client record #4.
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Plan of Correction
It is CJ CMHC's policy to ensure appropriate consent for disclosure of client information. The Facility Director &/or Project Director will ensure appropriate consents for release of information for all applicable funding sources are secured prior to release of information from the client record. All staff within the D&A department will be trained on this practice as a part of their department orientation. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of the administrative information on August 27, 2008, the facility failed to develop a data collection and record-keeping system that allowed for the efficient retrieval of data that would provide accurate client information.
Finding:
Program staff could not provide accurate client information from the facility's data collection and record-keeping system. The system did not allow for the efficient retrieval of data.
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Plan of Correction
CJ CMHC Chief Compliance Officer is in the process of implementation of an Electronic Medical Record that will ensure the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives. CJ CMHC will begin implementation of the Credible system in 10/08. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the project policy and procedure manual on August 25, 2008, the facility failed to develop a written client follow-up policy.
Finding:
There was no documentation of a written client follow-up policy at the time of the inspection.
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Plan of Correction
A written client follow-up policy has been established as of 9/30/08 by the Project Director. The policy will be implemented immediately as written and all staff will be oriented on 10/02/08 of the new policy. |