INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 27-29,2010 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 August 25, 2010.
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Plan of Correction
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed to ensure that hot water temperatures were within acceptable limits (120 degree Fahrenheit maximum) in each bathroom in the facility.
The findings included:
The facility has two bathrooms available for use, one for clients and one for staff. The temperature of the hot water was taken in each. Hot water temperatures were measured at 145 degrees Fahrenheit on July 29, 2010.
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Plan of Correction
The hot water tank was adjusted on 7/29/10 to ensure water temperatures are below 120 degrees Fahrenheit. A monthly check of the hot water tank will occur and be documented by maintenance personnel. |
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 the review of client records, the facility failed to document psychosocial evaluations which provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. The psychosocial evaluations were incomplete in five of five client records.
The findings included:
Five client records were reviewed on July 29, 2010. Each was required to include documentation of a psychosocial evaluation which addressed the required areas. Additionally, the evaluations were not consistently documented within the time frames specified in agency policy (at intake).
Record # 1 - admitted 3/3/10 - The psychosocial evaluation was completed on 3/9/10. The evaluation did not document support systems and coping mechanisms nor did it include a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
Record # 2- admitted 3/11/10 - The evaluation was completed on 3/23/10. The evaluation failed to include documentation of coping mechanisms and a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. There was no evaluative content in this document.
Record # 3 - admitted 11/23/09 - The evaluation was completed on 11/23/09. The evaluation failed to include documentation of coping mechanisms and a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
Record # 4 - admitted on 3/12/10 - The evaluation was completed on 3/12/10. The evaluation failed to document coping mechanisms and a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
Record # 5 - admitted 1/27/10 - The evaluation was completed on 1/27/10. The evaluation failed to include documentation of coping mechanisms.
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Plan of Correction
During a staff meeting on 8/3/10 staff was re-trained on the intake process. They are now to sign the initial treatment plan/psychosocial evaluation when it is completed, rather than waiting for the physician to review and approve the recommended level of care.
Staff members were also retrained on the structure of the psychosocial evaluation and techniques to gathering a composite picture of the individual in relationship to the collected historical information in order to identify relationships, conditions and causes to the client's current situation. The training outline developed by the intake department was reviewed. Training included ways to question and interview clients to gather more specific information. Items reviewed in detail included coping mechanisms, histories (specifically work, D&A, family) as well as including more clinical impressions and evaluation rather than a repeat of the information gathered.
Moving forward, both the D&A and Intake Director will be randomly auditing psychosocial evaluations to ensure that all components are covered. |
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 treatment plans which identified the type and frequency of services to be offered to the client in two of five client records.
The findings included:
Five client records were reviewed on July 29, 2010. Each was required to include documentation of a treatment plan which identified the type and frequency of services to be offered to each client.
Record # 1- admitted 3/3/10 - The treatment plan dated 4/2/10 failed to include documentation of the frequency of services to be offered to the client.
Record # 4 - admitted 3/12/10 - The treatment plan dated 4/5/10 failed to include documentation of the frequency of services to be offered to the client.
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Plan of Correction
During a staff meeting on 8/3/10, the therapists were re-trained on treatment plan formulation, specifically type and frequency of treatment rehabilitation services. The supervisor provided a copy of a sample treatment plan for referencing purposes. As on ongoing practice, treatment plans that do not clearly indicate type and frequency during chart audits and prior to signature will be returned to clinician for correction. Random chart audits by the supervisor as well as peer reviewed audits will continue to occur monthly. |
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.
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Observations
Based on the review of client records, the facility failed to document treatment plans which identified the type of support services to be offered to the client in two of five client records.
The findings included:
Five client records were reviewed on July 29, 2010. Each was required to include documentation of a treatment plan which identified the type and frequency of services to be offered to each client.
Record # 1- admitted 3/3/10 - The treatment plan dated 4/2/10 failed to include documentation of the support services to be offered to the client. .
Record # 5 - admitted 1/27/10 - The treatment plan dated 2/25/10 failed to include documentation of the support services to be offered to the client.
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Plan of Correction
During a staff meeting on 8/3/10, the therapists were re-trained on treatment plan formulation, specifically reviewing support services inclusion. The treatment plan document was also amended for the clinician to list the support services available to the client. The supervisor provided a copy of a sample treatment plan for referencing purposes. As on ongoing practice, treatment plans that do not clearly indicate support services during chart audits and prior to signature will be returned to clinician for correction. Random chart audits by the supervisor, as well as, peer-reviewed audits will continue to occur monthly. |
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 the review of client records, the facility failed to document follow up in accordance with timeframes specified in facility policy (at 90 days) in three of three closed client records.
The findings included:
Six client records were reviewed on July 29, 2010. There were three closed client records in the sample.
Record # 2- admitted 3/11/10 - This was an active client at the time of the review, however, the client had a previous treatment experience during the licensing review period. The client was in treatment from 5/26/09 to 10/19/09. No follow up was documented after the discharge which occurred on 10/19/09.
Record # 5 - admitted 1/27/10 and discharged 4/1/10 - Follow up was not documented until 7/23/10, 113 days post discharge.
Record # 6- admitted 10/23/09 and discharged 1/21/10 - Follow up was not documented until 5/7/10, 107 days post discharge.
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Plan of Correction
The Clinical Director will ensure that clients are receiving their Follow Up Surveys within the 90-day timeframe. Computer generated reports will be printed 60-75 days from the consumer's discharge date, then mailed by the Clinical Director prior to the 90-day discharge marker. Routine chart audits will be conducted by the Clinical Director to ensure that the follow-ups are being sent prior to the 90 day marker.
The 90 day follow-up letters for outstanding applicable consumers were printed on 8/11/10 and mailed on 8/16/10. |