INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18 to 20, 2007 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 October 18, 2007.
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the personnel record review on September 19, 2007 and a conversation with the director on September 19, 2007, it was determined that the facility failed to provide the direct observation supervision for personnel record #6.
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Plan of Correction
The Director began direct supervision observation with the staff in question immediately following the licensing visit. Documentation of the observation is being completed ongoing for the time period required. |
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 facility summary report and a conversation with the director on
September 19, 2007, it was determined that the facility gave a caseload of seven patients to a counselor assistant in the direct observation supervision period. Counselor assistants within the direct observation period are not permitted to carry caseloads. Refer to personnel record #6. Based on a review of the counselor caseloads and a conversation with the director on September 25, 2007, it was determined that the caseload for personnel record
#2 is 52 which exceeds the maximum of 35.
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Plan of Correction
The cases assigned to staff #6 were reassigned to the Director of the program effective September 27, 2007.
Upon completion of licensing no further cases were assigned to counselor #2. As he works between all three sites, the Director will monitor more closely his caseload size and advise when maximum is reached. Currently he is under the allowed 35. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during a physical plant inspection on September 18, 2007 at 11:00 AM, it was determined that the facility had a double key dead bolt on the second front entrance door. A conversation with the director indicated the first entrance door was addressed and corrected, but the second door was not corrected.
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Plan of Correction
Before the licensor left our facilty the second dead bolt was removed. The Director assured this action. |
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 a review of the board meeting minutes on September 18, 2007 and interviews with the the Director on September 18, 2007 and September 19, 2007, it was determined that the facility failed to provide documentation that the 2007 agency goals and objectives were presented to the board of directors.
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Plan of Correction
Goals and objectives were reviewed with the Board but no documentation could be found. This year's oals and objectives will be reviewed with the documentation found in the Board minutes but also in a sign off sheet at that particular meeting. The Director will prepare the goals and objectives as well as the sign off sheet for the Chief Executive Officer. |
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 an interview with the director on September 18, 2007, it was determined that the facility failed to complete an annual audit for the 2005-2006 year. This was an identified issue during the last licensing inspection.
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Plan of Correction
We have had a very difficult time in the various changes that have taken place within our agency in the last few years. Part of the difficulty is in a contract we have with an auditing firm that cannot meet our deadlines due to their size and workload. As a result, the 2005-2006 audit has been completed. We are working fervishly to have the 2006 -2007 completed in a timely fashion and are looking for alternative audit firms for future audits. The Controller and Chief Executive Officer will be responsible for assuring that this happens. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based on a facility inspection on September 18, 2007 and a conversation with the director on September 25, 2007, it was determined that the facility failed to post the fee schedule.
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Plan of Correction
A fee schedule was posted immediately following the licensing visit. The Director upon routine visits will assure that the schedule remains posted. |
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 client record review on September 18, 2007, and conversations with the director, it was determined that the facility failed to provide the type and frequency of services on the treatment plans. This occurred in four of nine client records reviewed, # 7, 8, 9, and 10.
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Plan of Correction
In staffing on September 27, 2007, treatment plan procedures were reviewed with all staff. Clerical monitoring and supervisory review will assure type and frequency to be included on all treatment plans. |
709.93(a)(2) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(2) Medication records.
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Observations
Based on a client record reviews on September 19, 2007 and September 21, 2007, it was determined that the facility failed to include dose and frequency on the medication record. This occurred in two of the three applicable client records reviewed, # 1 and #8.
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Plan of Correction
In staffing on September 27, 2007, the Director reviewed medication documentation. All staff were advised to complete information if not gained at the intake. Clerical monitoring and supervisory review will assure that medication information is complete. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records and a conversation with the director on September 21, 2007, it was determined that the facility failed to complete and provide the documentation for patient follow-up in two of four records. Refer to client records # 9 and 10.
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Plan of Correction
In staffing on September 27, 2007, the Director reviewed follow-up procedures. All staff were present. Clerical monitoring and supervisory review will assure compliance. |