INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 5-8, 2011 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 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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709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
Based on a review of the agency policy and procedure manual and a discussion with facility staff during the inspection, the facility failed to identify qualifications for Board members in policy or By Laws.
The findings included:
During the onsite inspection of July 5-8, 2011 the agency policy manual and the corporate Bylaws were reviewed. This review occurred on July 5, 2011. No qualifications for membership on the Board were specified in the documentation in the By Laws or in written agency policy.
During a dialogue with the Project and Facility Director on July 8, 2011 the Project Director acknowledged that there were no qualifications identified. The findings were not disputed.
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Plan of Correction
The project director will notify the Board of the need to adopt amended by-laws that shall include, but not be limited to, two (2) qualifications for Board membership. The project director will recommend, at a minimum, that the following two (2) qualifications be adopted:
1. Board members shall be at least 18 years of age.
2. Board members shall have an interest in mental health and/or substance abuse services.
The Board will meet to vote on these qualifications on September 13, 2011. The project director will immediately ensure that the by-laws are changed to reflect these qualifications after a signed resolution by the Board at that meeting. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative polices and procedures, the facility failed to document the annual update of a written manual delineating project polices and procedures.
The findings include:
The administrative policies and procedures were reviewed on July 5, 2011. The project director failed to document the annual update of the written project policies and procedures.
The findings were reviewed with the Project Director on July 8, 2011 at approximately 3:00 P.M. and were not disputed.
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Plan of Correction
The clinical supervisor has developed a sign-off sheet to be kept in the policy and procedure manual that will demonstrate that the project director has annually reviewed and updated the policies and procedures. The project director will have this completed each year by June 30. The current drug and alcohol policies and procedures will be reviewed by the project director and signed off by September 13, 2011. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on the review of the facility policy and procedure manual and administrative reports on July 5, 2011 and an interview with the Clinical Director on July 6, 2011, the facility failed to document collaboration between the project director and governing body in formulating annual goals and objectives for the current fiscal year.
The findings included:
The annual onsite licensing inspection was conducted on July 5-8, 2011. As part of the inspection the facility policy and procedure manual and administrative reports were reviewed. No documentation was presented to demonstrate that the Project Director and the governing body collaborated on the formulation of goals and objectives for the fiscal year which began on July 1, 2011.
When this issue was identified by Division staff it was brought to the attention of the Clinical Supervisor who was assisting with the licensing process. The Clinical Supervisor was unable to produce the required documentation. The findings were reviewed with the Project Director on July 8 , 2011 at approximately 2:45 P.M. and were not disputed.
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Plan of Correction
The project director will develop project goals and objectives and present them to the Board of Directors in June of each year. The project director will present the project goals and objectives for fiscal year 2011-2012 at the next board meeting on September 13, 2011. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of the facility policy and procedure manual and administrative reports on July 5, 2011 and an interview with the Clinical Director on July 6, 2011, the facility failed to document annual goals and objectives for the current fiscal year.
The findings included:
The annual onsite licensing inspection was conducted July 5-8, 2011. As part of the inspection the facility policy and procedure manual and administrative reports were reviewed. No documentation was presented to demonstrate that the Project Director and the governing body formulated annual goals and objectives for the fiscal year which began on July 1, 2011.
When this issue was identified by Division staff it was brought to the attention of the Clinical Supervisor who was assisting with the licensing process. The Clinical Supervisor was unable to produce the required documentation. The findings were reviewed with the Project Director on July 8 , 2011 at approximately 2:45 P.M. and were not disputed.
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Plan of Correction
The project director will have the Board of Directors sign-off approval of the project goals and objectives at the June board meeting each year. The Board of Directors will sign-off on this year's project goals and objectives for fiscal year 2011-2012 at the next board meeting on September 13, 2011. |
709.26(a)(11) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(11) Employe accidents and safety.
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Observations
Based on a review of the facility policy and procedure manual and the agency safety manual, the facility failed to document a policy and procedure for the reporting of unsafe conditions at the facility.
The findings included:
The annual onsite licensing inspection was conducted on July 5-8, 2011. As part of the inspection the facility personnel policies and procedures were reviewed. The Clinical Supervisor, who was assisting with the licensing process was made aware of the missing policy and procedure on July 5, 2011 and again on July 8, 2011 and was unable to provide documentation of a written policy and procedure which addressed this requirement.
The findings were reviewed with the Project Director on July 8, 2011 and were not disputed.
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Plan of Correction
The intake director/safety committee chair and the clinical supervisor have developed a policy and procedures for employee accidents and safety. The policy and procedure will be presented to the project director and Board of Directors for approval at the September 13, 2011 board meeting. The policy will be distributed to all current employees and will be reviewed with new hires at orientation training during the safety training portion. |
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 the review of the facility policy and procedure manual, the facility failed to document a confidentiality policy that addressed 4 Pa .Code subsection 255.5 correctly and failed to address related confidentiality laws and regulations.
The findings included:
On July 5, 2011 and again on July 8, 2011, the facility policy and procedure on confidentiality was reviewed by Division staff. Drug & Alcohol Policy # 16, page 4, section C, subsections (i), (ii), and (iii) incorrectly state that releases of information can be made without client consent to judges and probation/parole officers. The policy also fails to address 4 Pa. Code subsection 255.5 (a)(6) which specifies limitations on client information which may be released to employers.
In addition, the facility's Drug & Alcohol policy references Mental Health policies found in the facility mental health manual. The specific policies referenced include PRI 04, 15, 20 and 21. Policy PRI 15 Subject: Uses and Disclosures for Treatment, Payment and Healthcare operations, outlines instances in which the facility may use client identifying information (PHI - Personal Health Information) for treatment, payment and healthcare operations. This document does not make it clear that for clients receiving Drug & Alcohol treatment and for any information in mental health records that identifies an individual as a "drug abuser" or a "drug dependent person" as defined at 71 P.S. subsection 1690.102, consent must be obtained before releasing any of this information to anyone except where a judge of the Court of Common Pleas or a higher court has issued a court order to release the information.
The findings were reviewed with the Clinical Supervisor and the Project Director and were not disputed.
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Plan of Correction
The clinical supervisor will revise the confidentiality policy to comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information) and present it to the Board of Directors at the board meeting on September 13, 2011 for approval. Once the policy is approved the clinical supervisor will review and distribute the updated policy at a departmental meeting. All therapists will sign-off that they have received and understand the updated confidentiality policy and the clinical supervisor will keep the sign-off with policy in the policy and procedure manual. As new personnel are hired the confidentiality policy will be reviewed and signed off on as part of the new hire orientation within 7 days of hire. This process is overseen by the clinical supervisor. |
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 client records during the annual onsite licensing inspection of July 508, 2011, the facility failed to document an informed and voluntary consent to release client identifying information in five of thirteen client record reviewed.
The findings include:
Thirteen client records were reviewed during the onsite licensing inspection conducted on July 5-8, 2011. Consent to release information forms documented in five of thirteen client records failed to include each of the components required for a valid consent to release information form.
Client # 1 was admitted on 5/27/11 and was last treated on 6/30/11. A consent to release information dated 6/21/11 did not identify the specific information to be released. A second consent to release information form dated 6/30/11, where a physician was the identified recipient, did not identify the purpose for the release of information to the physician.
Client #4 was admitted on 1/2/11 and discharged on 7/1/11. A consent to release information form dated 5/16/11, where the Single County Authority was the identified recipient, did not identify the purpose for the release of information.
Client # 5 was admitted on 5/16/11 and last treated on 7/6/11. A consent to release information form dated 5/6/11, where the Jefferson County Prison was the identified recipient, did not identify the purpose for the release of information.
Client # 6 was admitted on 6/27/11 and was last seen on 6/27/11. A consent to release information form dated 6/27/11, where the Single County Authority was the identified recipient, did not identify the specific information to be released. The specific information to be released and the purpose for the release were identical and stated, " Mileage/attendance".
Client # 13 was admitted on 6/27/11 and was last seen on 7/6/11. A consent to release information form dated 6/27/11, where the Single County Authority was the identified recipient, did not identify the specific information to be released but included the comment " emergency purposes only" in that section of the consent to release information form. The facility failed to specify what information would be released in an emergency.
The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
At a departmental meeting scheduled on Wednesday, July 20, 2011, the clinical supervisor retrained all personnel on properly completing releases of information. The clinical supervisor will meet with the intake personnel by August 3, 2011 and retrain them, as well. Each month the intake director will audit 5 charts and monitor for the proper completion of the releases of information. If deficiencies are found, the chart will be returned to the appropriate staff for correction. |
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.
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Observations
Based on the review of client records, the facility failed to document complete personal histories in 8 of 13 client records reviewed.
The findings included:
Thirteen client records were reviewed during the inspection conducted from July 5-8, 2011. Clinical staff failed to follow the instructions and prompts written on the personal history form, developed by the facility, which requested the required details for a complete personal history.
Client record # 1- This client was admitted on 5/27/11 and was last treated on 6/30/11. The personal history on file in this record failed to document family interrelationships defining relationships only in terms of being "good" or " great" or recreational interests that the client may have that did not include references to the impact of substance use on those recreational activities.
Client record # 2- This client was admitted on 6/21/11 and was last seen on 7/2/11. The personal history on file in this record failed to document family interrelationships, details of the client's legal history and educational history.
Client record # 5- This client was admitted on 5/6/11 and was last treated on 7/6/11. The personal history on file in this record failed to document family interrelationships defining them only with a + or - sign. The educational history did not explore any strengths or interests the client had while in school or relationships with others but stated only that the " client dropped out of school after opiates". The sexual history did not identify the client's sexual preference.
Client record # 6- This client was admitted on 6/27/11 and was last seen on 6/27/11. The personal history on file in this record failed to include documentation of family interrelationships and recreational interests.
Client record # 7- This client was admitted on 11/15/10 and was last seen on 6/3/11. The personal history on file in this client record failed to include documentation of family interrelationships and a complete employment history.
Client record # 9- This client was admitted on 9/22/10 and was last seen on 3/24/11. The client was discharged on 4/5/11. The personal history on file in this record failed to include documentation of family interrelationships and pertinent details in the educational history regarding relationships in school.
Client record # 10- This client was admitted on 6/10/11 and was last seen on 7/7/11. The personal history on file in this client record failed to include documentation of family interrelationships and sexual preference. The historical data documented alluded to parental addiction but did not detail the client's perspective on the impact of the parents substance use.
Client record # 11- This client was admitted on 6/22/11 and was last seen on 6/29/11. The personal history on file in this client record failed to include documentation of family interrelationships. The work history was incomplete, accounting for only one month in the life of this 31 year old client. Comments in the history referred to behavioral problems in school but gave no details on the nature of the problems or the impact drug and alcohol use may have had.
The findings were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
At a departmental meeting scheduled on Wednesday, July 20, 2011, the clinical supervisor retrained all personnel on properly completely personal histories in the intake packet on. The clinical supervisor will meet with the intake personnel by August 3, 2011 and retrain them, as well. Each month the intake director will audit 5 intakes and monitor for the proper completion of personal histories. If deficiencies are found, the chart will be returned to the appropriate staff for correction. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client record documentation, the facility failed to document psychosocial evaluations in a timely manner which complied with written facility policy in 5 of 13 client records reviewed.
The findings included:
Thirteen client records were reviewed during the onsite inspection. Facility policy required that psychosocial evaluations be completed within 48 hours.
Client record # 3- The client was admitted on 5/4/11. The psychosocial evaluation was not completed until 5/24/11 .
Client record # 4- The client was admitted on 1/2/11. The psychosocial evaluation was not completed until 1/27/11.
Client record # 5- The client was admitted on 5/6/11. The psychosocial evaluation was not completed until 5/24/11.
Client record # 10- The client was admitted on 6/10/11. The psychosocial evaluation was not completed until 6/14/11.
The findings were reviewed with the clinical Supervisor and were not disputed.
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Plan of Correction
At a departmental meeting scheduled on Wednesday, July 20, 2011, the clinical supervisor reviewed with all personnel the timeframe for completing the psychosocial evaluation. The clinical supervisor will meet with the intake personnel by August 3, 2011 and review the timeframe with them, as well. Each month the intake director will audit 5 intakes and monitor for the timely completion of the psychosocial evaluation. If deficiencies are found, the timeframe will be addressed again in supervision and the necessary disciplinary action will be taken. |
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 record documentation, the facility failed to document individual treatment plans in a timely manner which complied with written facility policy in 4 of 13 client records reviewed. A treatment plan was missing from one treatment record.
The findings included:
Thirteen client records were reviewed during the onsite inspection. Treatment plans were required to be completed within 30 days of admission in accordance with written facility policy and procedure.
Client record # 1- The client was admitted on 5/27/11. The treatment plan was not documented until 6/30/11.
Record # 3 - The client was admitted on 5/4/11. The treatment plan was not documented until 6/21/11.
Record # 4- The client was admitted on 1/2/11. The treatment plan was not documented until 2/4/11.
Record # 7- The client was admitted on 11/15/10. The treatment plan was not documented until 1/10/11.
Record # 8- The client was admitted on 1/24/11. There was no documentation of a treatment plan as of 7/6/11.
The findings were reviewed with the clinical Supervisor and were not disputed. .
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Plan of Correction
At a departmental meeting scheduled on Wednesday, July 20, 2011, the clinical supervisor reviewed with all personnel the timeframe for completing treatment plans. Each month the clinical supervisor will audit 5 charts and monitor for the timely completion of treatment plans. If deficiencies are found, the timeframe will be addressed again in supervision and the necessary disciplinary action will be taken. |
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 the review of client records, the facility failed to document the type and frequency of treatment on each treatment plan. Three of seven client records failed to document either type or frequency of services to be offered to the client on the treatment plan.
The findings included:
Thirteen client records were reviewed during the annual onsite licensing inspection conducted from July 5- 8, 2011. Seven of these were required to include treatment plans which included documentation of the type and frequency of services to be offered to the client. One treatment plan that should have included this information was missing and three treatment plans reviewed did not include documentation of the type and/or frequency of treatment on the treatment plan.
Client record # 3- The client was admitted on 5/6/11 and the treatment plan was formulated on 6/21/11. The frequency of service to be offered was not documented on the treatment plan.
Client record # 5- The client was admitted on 5/4/11 and the treatment plan was formulated on 5/6/11. The frequency and type of service to be offered was not documented on the treatment plan.
Client record # 7- The client was admitted on 11/15/10 and the treatment plan was formulated on 1/10/11. The frequency and type of service to be offered was not documented on the treatment plan.
Client record # 8- The client was admitted on 1/24/11. Facility policy requires formulation of a treatment plan which contains all required components including type and frequency of services to be offered within 30 days of admission. No treatment plan was documented in this record.
The findings were reviewed with the Clinical Supervisor and were not disputed.
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Plan of Correction
At a departmental meeting scheduled on Wednesday, July 20, 2011, the clinical supervisor reviewed/retrained personnel on properly formulating individual treatment plans with the type and frequency of services. On July 21, 2011, the comprehensive and treatment plan review forms have been revised to include type and frequency on the forms. They were distributed to all staff on July 25, 2011 and staff was instructed to use the new forms effective immediately. Each month the clinical supervisor will audit 5 charts and monitor for the timely completion of treatment plans. If deficiencies are found, the chart will be returned to the appropriate staff for correction and the necessary disciplinary action will be taken. |