INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the July 29, 2010 licensure renewal inspection. The follow-up inspection was conducted on March 31, 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 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.
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Plan of Correction
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of client records, the facility failed to include documentation of a medical history on each client which addressed family, and personal medical history and symptoms and illnesses in two of four client records.
The findings included:
Four client records were reviewed during the plan of correction follow up inspection of 3/31/11. Two of four client records reviewed failed to include documentation of complete medical histories.
Client record # 1 - This client was admitted on 11/12/10. Documentation of the medical history consisted of the comment "no", which was listed on the history form.
Client record # 4 - This client was admitted on 1/18/11. The medical history did not include documentation of a family medical history and did not address symptoms/illnesses on the history form which were mentioned elsewhere in the client record.
The findings were reviewed with the clinical supervisor and were not disputed.
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Plan of Correction
The clinical supervisor will update the intake packet to ensure detailed medical history is obtained, including family and personal medical histories, as well as, symptoms and illnesses. 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 the consumer's medical history. 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)(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 a review of client record documentation, the facility failed to document complete personal histories which addressed family relationships and employment histories in four of four client records.
The findings included:
At the time of the plan of correction follow up inspection, four client records were reviewed. Each was required to have a complete personal history which addressed: family, employment, education, military, sexual, recreational and legal history in detail. Four of four records reviewed failed to address the personal history requirements in detail.
Client record # 1 - This client was admitted on 11/12/10 . The personal history documented in the record failed to address family interrelationships, the employment history listed only the client's current job and did not document a work history, support systems available to the client were not documented, the educational history did not address school performance/relationships; and no recreational interests were included in the documentation of the client's history. This record was reviewed on 3/31/11.
Client record # 2 - This client was admitted on 2/16/11 . The personal history documented in the record failed to address family interrelationships in the documentation of the client's history. This record was reviewed on 3/31/11.
Client record # 3 - This client was admitted on 12/14/11. The personal history documented in the record failed to address family interrelationships and the client's work history in the documentation of the client's history. This record was reviewed on 3/31/11.
Client record # 4- This client was admitted on 1/18/11 . The personal history collected and documented in the record failed to address family interrelationships and the client's recreational interests in the documentation of the client's history. This record was reviewed on 3/31/11.
The findings were reviewed with the clinical supervisor and were not disputed.
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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.
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Observations
Based on a review of client record documentation, the facility failed to document psychosocial evaluations which addressed coping mechanisms, support systems, assets/strengths and clinical impressions in four of four client records.
The findings included:
Four client records were reviewed during the plan of correction follow up inspection on March 31, 2011.
Client record # 1 was admitted on 11/12/10. The psychosocial evaluation was completed on that date. The psychosocial evaluation failed to include documentation of the counselor's perspective of the client's treatment needs, assets/strengths, available support systems and the counselor's clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation.
Client record # 2 was admitted on 2/16/11. The psychosocial evaluation was completed on that date. The psychosocial evaluation failed to document the client's coping mechanisms, assets and strengths and the counselor's clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation.
Client record # 3 was admitted on 12/14/10. There was no documentation of a psychosocial evaluation in the record.
Client record # 4 was admitted on 1/18/11. The psychosocial evaluation was completed on that date. The psychosocial evaluation failed to include documentation of the counselor's clinical impressions which identified possible relationships, conditions and causes leading to the client's current situation and failed to address the client's coping/defense mechanisms.
The findings were reviewed with the clinical supervisor and were not disputed.
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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. |