INITIAL COMMENTS
|
This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 28, 2010 licensure renewal inspection. The follow-up inspection was conducted on March 30, 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 and a plan of correction is due on April 26, 2011.
|
Plan of Correction
|
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.
|
Observations
Based on a review of the counselor caseloads and an interview with the Clinical Supervisor, the facility failed to ensure that the maximum allowable staff to client caseload is maintained at all times in the outpatient D&A program.
The findings included:
The counselor caseloads for each counselor at this facility were reviewed . The caseload for employee # 3 was documented as 37 individuals. The clinical supervisor was interviewed on 3/31/11 and acknowledged that there has been some difficulty finding qualified counselors and that client to counselor caseloads do exceed the 35:1 maximum on occasion.
|
Plan of Correction
The agency has added one additional staff member since the visit on March 30, 2011 and is in the process of hiring another full-time staff person. Additionally, as appropriate, clients have been discharged. With the additional staff caseloads will be reduced to comply with the 35:1 ratio identified in 704.12. The clinical supervisor will continue to monitor this area and hire additional staff as the need arises. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained in emergency procedures on the date of employment.
The findings include:
Three personnel records were reviewed. Each personnel record required documentation of the emergency procedure training. The facility failed to document the completion of emergency procedure training upon employment in personnel records reviewed.
Employee # 1 was hired on 11/23/10. Emergency procedures training was due upon employment. No training documentation was on file in this record to verify that the employee had received emergency procedure training. The record was reviewed on 3/30/11.
Employee # 2 was hired on 2/17/11. Emergency procedures training was due upon employment. No training documentation was on file in this record to verify that the employee had received emergency procedure training. The record was reviewed on 3/30/11.
Employee # 3 was hired on 12/16/11. Emergency procedures training was due upon employment. No training documentation was on file in this record to verify that the employee had received emergency procedure training. The record was reviewed on 3/30/11.
The findings were reviewed with the Clinical Supervisor and were not disputed.
|
Plan of Correction
The clinical supervisor will train all personnel on April 20, 2011 at a staff meeting to ensure all personnel know their assigned tasks during emergencies. Completion of the training will be documented in the staff meeting minutes. In the future, all new hires will be trained during new staff orientation and will sign off on the training within the first 7 days of employment. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
|
Observations
Based on the review of personnel records during the unannounced inspection of 3/30/2011, the facility failed to document job descriptions which contained the signature of the supervisor and the employee in three of three personnel records reviewed.
The findings included:
At the time of the unannounced inspection on 3/30/2011 the records of three clinical staff were reviewed. Each record was required to include documentation of the dated signature of the employee and the supervisor on the job description. In three of three personnel records reviewed the supervisor failed to sign the job description as required.
Record #1 - This employee was hired on 11/23/10. A job description was filed in this employee record. The job description did not have the dated signature of the supervisor. The employee signed the job description but the signature was not dated.
Record # 2- This employee was hired on 3/16/09 and was transferred into the D&A department on 12/16/11. A job description dated 2/18/11 contained the dated signature of the employee but did not contain a dated signature for the supervisor.
Record # 3- This employee was hired on 1/8/10 and was transferred into the D&A department on 2/17/11. A job description dated 12/18/10 contained the dated signature of the employee but did not contain a dated signature for the supervisor.
|
Plan of Correction
On April 15, 2011 all drug and alcohol job descriptions were updated to include the signature and date of both the supervisor and employee. This was completed by the HR Specialist and the clinical supervisor. The HR Specialist will ensure that all future hires and the clinical supervisor sign and date the job descriptions on their first day of employment. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
|
Observations
Based on a review of client record documentation, the facility failed to document personal histories which addressed family relationships and educational and employment histories in five of five client records.
The findings included:
At the time of the onsite inspection five client records were reviewed. Each was required to include documentation of a personal history which addressed: family, employment, education, military, sexual, recreational and legal history in detail. Five records reviewed on March 30, 2011 failed to include documentation of the personal history requirements in detail.
Client record # 1 - This client was admitted on 10/6/10. The personal history was completed on that date as part of the intake process. The history in this record failed to document family interrelationships and a complete employment history.
Client record # 2 - This client was admitted on 10/4/10. The personal history was completed on that date as part of the intake process. The history in this record failed to include documentation of family interrelationships and a complete employment history.
Client record # 3 - This client was admitted on 3/17/11 . The personal history was completed on that date as part of the intake process. The history in this record failed to include documentation of family interrelationships and a complete employment history . The client's sexual orientation was not identified as part of the client history that was documented.
Client record # 4 - This client was admitted on 1/31/11 . The personal history was completed on that date as part of the intake process. The history in this record failed to include documentation of family interrelationships and a complete employment history. The client's sexual orientation was not identified as part of the client history documented.
Client record # 5 - This client was admitted on 1/28/11 . The personal history was completed on that date as part of the intake process. The history in this record failed to include documentation of family interrelationships and a complete employment history.
The findings were reviewed with the clinical supervisor and were not disputed.
|
Plan of Correction
The clinical supervisor will update the intake packet to ensure detailed personal histories are obtained, including family relationships, as well as, educational and employment histories. The intake packet will be updated and implemented by May 30, 2011. All personnel conducting intakes will be trained on the new intakes prior to the implementation date. At the staff meeting scheduled on Wednesday, April 20, 2011, the clinical supervisor will train personnel on obtaining and documenting more detailed personnel histories. The clinical supervisor will randomly pull five charts per month to audit. If deficiencies are found, the chart will be returned to the appropriate staff for corrections. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client record documentation, the facility failed to document complete psychosocial evaluations which addressed coping mechanisms, support systems, assets/strengths and clinical impressions in five of five client records reviewed.
The findings included:
Five client records were reviewed during the plan of correction follow up inspection. The documents identified as the psychosocial evaluation, in each client record reviewed, was a summary of the client history rather than a clinical evaluation of the client's needs and how treatment would be managed to address the identified needs.
Client record # 1 was admitted on 10/6/10 . No psychosocial evaluation was documented in this record . This record was reviewed on 3/30/2011.
Client record # 2 was admitted on 10/4/10 . The psychosocial evaluation was completed on 10/4/10 . The psychosocial evaluation failed to include documentation of support systems available to the client, the client's coping mechanisms or the clinical impressions of the counselor which identified possible relationships, conditions and causes leading to the client's current situation. This record was reviewed on 3/30/2011.
Client record # 3 was admitted on 3/17/11 . The psychosocial evaluation was completed on 3/17/11 . The psychosocial evaluation failed to include documentation of a composite picture of the client, a clear statement of the client's treatment needs, the counselor's impression of the client's strengths, available support systems, coping mechanisms or the clinical impressions of the counselor which identified possible relationships, conditions and causes leading to the client's current situation . This record was reviewed on 3/30/2011.
Client record # 4 was admitted on 1/31/11 . The psychosocial evaluation was completed on 1/31/11. The psychosocial evaluation failed to include documentation of the clinical impressions of the counselor which identified possible relationships, conditions and causes leading to the client's current situation, the client's coping mechanisms, negative factors which could effect the client's progress in treatment or a composite picture of the client. This record was reviewed on 3/30/2011.
Client record # 5 was admitted on 1/28/11. The psychosocial evaluation was completed on 1/29/11. The psychosocial evaluation failed to include documentation of the clinical impressions of the counselor which identified possible relationships, conditions and causes leading to the client's current situation, negative factors which might impact the client's treatment, the counselor's impressions of the client's strengths and a composite picture of the client. This record was reviewed on 3/30/2011.
The findings were reviewed with the clinical supervisor and were not disputed.
|
Plan of Correction
The clinical supervisor will update the intake packet to ensure complete psychosocial evaluations are obtained, including coping mechanisms, support systems, assets/strengths, and clinical impressions. The intake packet will be updated and implemented by May 30, 2011. All personnel conducting intakes will be trained on the new intakes prior to the implementation date. At the staff meeting scheduled on Wednesday, April 20, 2011, the clinical supervisor will train personnel on obtaining and documenting complete psychosocial evaluations. The clinical supervisor will randomly pull five charts per month to audit. If deficiencies are found, the chart will be returned to the appropriate staff for corrections. |
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.
|
Observations
Based on the review of client records, the facility failed to document the type and frequency of service to be offered to the client on the treatment plan in three of four client records reviewed.
The findings included:
During the onsite inspection conducted on March 30, 2011, five client records were reviewed. Four client records were required to include documentation of the type and frequency of treatment to be offered to each client on the treatment plan. One record was NA for the treatment plan due to the length of time the client had been in treatment. Three of four client records failed to include documentation of either the type or frequency of service to be offered to the client.
Client record # 2 - This client was admitted on 10/4/10. The treatment plan was formulated on 11/5/10. The type/frequency of treatment was not documented on the treatment plan.
Client record # 4 - This client was admitted on 1/31/11. The treatment plan was formulated on 3/12/11. The type/frequency of treatment was not documented on the treatment plan.
Client record # 5 - This client was admitted on 1/28/11. The treatment plan was formulated on 2/23/11. Only the type of treatment was documented on the treatment plan. There was no documentation of the frequency of services on the treatment plan.
This is a repeat citation. The findings were reviewed with the clinical supervisor and were not disputed.
|
Plan of Correction
On April 6, 2011, the clinical supervisor trained/retrained staff on properly formulating individual treatment plans with the type and frequency of service offered to the client. Individualized treatment plans that are submitted for signature without clearly indicating type and frequency will be returned to the clinician for correction. |
709.92(a)(3) 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:
(3) Proposed type of support service.
|
Observations
Based on the review of client records during the onsite licensing inspection of 3/30/2011 , the facility failed to document the proposed type of support service on each treatment plan in each client record.
The findings included:
Five client records were reviewed during the plan of correction follow up inspection. Four records were required to include documentation of the proposed type of support service on the treatment plan. Four of four client records failed to include documentation of the type and frequency of treatment on the treatment plan.
Client record # 1 - This client was admitted on 10/6/10. The treatment plan was formulated on 11/5/10. No support services were documented on the treatment plan at the time of the review on 3/30/2011.
Client record # 2 - This client was admitted on 10/ 4/10. The treatment plan was formulated on 11/4/10. No support services were documented on the treatment plan at the time of the review on 3/30/2011.
Client record # 4 - This client was admitted on 1/31/11. The treatment plan was formulated on 3/12/11. No support services were documented on the treatment plan at the time of the review on 3/30/11.
Client record # 5 - This client was admitted on 1/28/11. The treatment plan was formulated on 2/23/11. No support services were documented on the treatment plan at the time of the review on 3/30/11.
This is a repeat citation. The findings were reviewed with the Clinical Supervisor and were not disputed.
.
|
Plan of Correction
On April 6, 2011, the clinical supervisor trained/retrained staff on properly formulating individual treatment plans with the type of support service (i.e. services currently enrolled in or services clinician is recommending). Individualized treatment plans that are submitted for signature without clearly indicating type of support service will be returned to the clinician for correction. |