INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 27, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, MinSec Treatment, LLC. 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
On June 27, 2016 six personnel records were reviewed. Four personnel records were required to have documentation of their qualifications for the position of counselor. The facility failed to provide documentation of counselor qualifications in personnel record #5.Employee # 5 was hired as a counselor on March 16, 2015. Employee #5 has a Bachelor of Science in Criminal Justice but did not have one year direct D&A experience. Employee #5 was correctly demoted to Counselor Assistant in June 2015, however was promotoed back to position of counselor on December 22, 2015, after only 6 months of supervision/expereince. These findings were reviewed with the facility staff. This is repeat citation.
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Plan of Correction
Employee #5 has been established and recognized as a counselor assistant effective 6/28/16. Employee #5 will receive weekly supervisions with lead counselor starting 6/28/16. Counselor's Assistant will be monitored for 6 months for development and ability to provide quality services.
Director has developed a training plan which incorporates core counseling competencies in chemical dependency to guide counselor assistant development during the 6 month period.
To meet ongoing compliance,director will ensure all candidates for hire meet with Standard 704.7 Compliance with code :7/27/2016 |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Six personal records were reviewed on June 27, 2016.Employee #5 was hired as a counselor on March 16, 2015 and as of the date of the licensing inspection failed to complete the required TB/STD trainings. These findings were reviewed with the facility staff.
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Plan of Correction
Director will ensure employee#5 is enrolled in September8,2016 TB/STD trainings at BHTEN. Mandatory TB/ STD training will be incorporated into annual training plan. Record of training will be maintained in each employee's training file. Director will ensure incoming staff have mandatory training. Compliance with code:9/8/2016 |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Six personnel records and CPR certification cards were reviewed on June 27, 2016. Only two employees had current CPR certification. The facility is open Monday - Thursday, 8:00 AM - 9:00 PM and Friday and Saturday from 8:00 AM - 5 PM. Facility director provided 4 week schedule and after review there were 13 days when the facility failed to have sufficient CPR coverage:May 26- 5:00 PM to 9:00 PMMay 27- 3:51 PM to 5:00 PMMay 28- 9:00 AM to 5:00 PMJune 1- 12:11 PM to 5:00 PMJune 4- 9:00 AM to 3:00 PMJune 8- 9:00 AM to 5:00 PMJune 9- 5:00 PM to 9:00 PMJune 10- 4:30 PM to 5:00 PMJune 11- 9:00 AM to 5:00 PMJune 13- 9:00 AM to 5:00 PMJune 14- 4:29 PM to 5:00 PMJune 15- 3:30 PM to 9:00 PMJune 21- 5:30 PM to 6:00 PMThese findings were reviewed with facility staff.
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Plan of Correction
Director has scheduled certified CPR/First Aid staff persons for morning shift and afternoon shift. Newly hired CPR/First Aid certified Lead counselor's (6/27/16) schedule overlaps shifts until 9:00 pm which will be implemented 6/28/16. Certified CPR/First Aid staff will cover for each other for meals and breaks. CEC Erie CPR facility trainer will provide CPR/First Aid training to all staff. |
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
The physical plant inspection was conducted on June 27, 2016 at 1:15 pm. During the inspection of the facility restrooms the male restroom's hot water temperature was measured at 122 degrees F and the female restroom's hot water temperature was measured at 121 degreees F. These findings were reviewed with facility staff.
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Plan of Correction
Director will have maintenance staff adjust hot water temperature to under 120F as per standard 705.24 in both men and women restroom by 7/22/16. Maintenance and operations staff will conduct monthly checks of hot water temperature to ensure compliance. Compliance with code: 7/22/2016 |
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 the physical plant inspection conducted on June 27, 2016, the facility failed to provide an unobstructed egress from the rear exit. The rear door was locked with four sliding bolt locks limiting egress at the rear exit from the facility. These results were revieiwed with facility staff.
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Plan of Correction
Operations counselor will unlock rear exit bolts when opening the facility, to ensure unobstructed egress from the facility during hours of operation. Operations staff will lock rear exit door when facility closes,effective immediately. Operations staff will monitor rear exit door periodically during the day, to ensure unobstructed egress daily. effective immediately. Compliance with code: 7/22/2016 |
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.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for release of information in client records, # 1 and #5. Additionally, client records, # 1 and #5 had consent forms that were missing the specific name of person to whom information was to be released and/or the purpose of the information to be released.4 Pa. Code states that information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of the code, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:(1) Whether the client is or is not in treatment.(2) Client's prognosis.(3) The nature of the project.(4) A brief description of the client's progress.(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.Client #1 was admitted on 2/17/16 and was still an active client as of the date of the licensing inspection. A consent form to Probation/Parole dated 2/17/16 allowed for the disclosure of information beyond what is permitted by 4 Pa. code 255.5 by allowing the release of the client's continuing care plan. Additionally, a consent form to the client's emergency contact dated 2/17/16 did not contain the name of the person to whom information was to be released and two consents forms dated 2/17/16, one to a government agency and one to an individual, did not contain the purpose for the releases.Client #5 was admitted on 2/10/16 and was still an active client as of the date of the licensing inspection. A consent to release information to DOC dated 2/10/16 allowed for the disclosure of information beyond what is permitted by 4 Pa. code 255.5 by allowing the release of the client's continuing care plan, 'any incidences of relapse and name of substance ', and the client's discharge summary. Additionally, a consent form to the client's emergency contact dated 2/10/16 did not contain the name of the person to whom information was to be released and two consent forms dated 2/10/16, one to a government agency and one to an individual, did not contain the purpose for the releases.This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client records #1 and#5 will have consent forms redone to adhere to Pa.Code 255.5, including specific names of persons information is to be released effective immediately. Erie staff will participate in state mandated trainings on Confidentiality at BHTEN within 6 months. Director and clinical supervisor will conduct in-house trainings to educate staff on how to complete releases of information forms during staff meetings beginning 7/22/2016. Clinical supervisor will oversee intake documentation to ensure adherence to the five areas listed in Pa.Code 255.5. Director and clinical supervisor will conduct staff trainings on documentation, specifically emergency contact forms during staff meetings beginning 7/22/16. Clinical supervisor will review all participant charts weekly to ensure emergency contact forms have names, purpose and hold accurate information. Compliance with code:7/22/2016 |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
The facility's Policy and Procedure manual was reviewed during the licening inspection on June 27, 2016 and was found not to be in compliance with State regulation 709.34 Reporting of unusual incidents.Facility policy failed to include the reporting of the unusual incidents as per 709.34, subsection (c): To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:(1) Physical or sexual assault by staff or a client. (2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances. (3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day. (4) Event at the facility requiring the presence of police, fire or ambulance personnel. (5) Outbreak of a contagious disease requiring CDC notification.This information was reviewed with facility staff.
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Plan of Correction
Director will incorporate state regulation 709.34,identifying the need to file a written unusual incident report to the Department of Drug and Alcohol Programs, into the current CEC policy for critical incident and reporting. Director will send revised policy to corporate office for approval. Compliance with code: 8/1/2016 |
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
Ten client records were reviewed on June 27, 2016, the facility failed to document a comprehensive treatment plan during intake in three of ten client records.Client #2 was admitted on 1/20/16 and was still an active client as of the date of the licensing inspection. A preliminary treatment plan dated 1/20/16 was documented however, the comprehensive treatment plan was not completed and signed by client and staff until 4/11/16 which is outside of the intake period.Client #3 was admitted on 4/14/16 and was still an active client as of the date of the licensing inspection. A preliminary treatment plan dated 4/14/16 was documented however, the comprehensive treatment plan was not documented in the chart during the intake period.Client #4 was admitted on 1/4/16 and was still an active client as of the date of the licensing inspection. A preliminary treatment plan dated 1/4/16 was documented however the comprehensive treatment plan was not completed and signed by client and staff until 3/23/16 which is outside of the intake period.This information was reviewed with facility staff.
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Plan of Correction
A spreadsheet with each client's treatment plan due date will be created and monitored by the clinical supervisor to ensure timely completion of the treatment plan. Clinical staff will be given email alerts indicating when a plan is due for clients on caseload. Client #3 will have treatment plan developed immediately. Clinical supervisor and lead counselor will review new admit charts weekly to monitor completion of comprehensive plans inside charts within intake period. Compliance with code: 7/27/2016 |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Two of five client records were reviewed on June 27, 2016, the facility failed to document a treatment plan update. Client #2 was admitted on 1/20/16 and was still an active client as of the date of the licensing inspection. The comprehensive treatment plan was documented on 4/11/16 however, there was no documentation of a treatment plan update in the client record as of the date of the licensing inspection. Client #4 was admitted on 1/4/16 and was still an active client as of the date of the licensing inspection. The comprehensive treatment plan was documented on 3/23/16 however, the treatment plan update was not completed until 6/1/16 which is outside the 60-day timeframe.This information was reviewed with facility staff.
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Plan of Correction
Client #2 treatment plan will be updated immediately. Utilization of the spreadsheet will ensure individual's treatment plans are developed within the 60 day timeframe. Director will develop a system for documentation to be submitted and reviewed daily by clinical supervisor and lead counselors.Clinical supervisor and lead counselor will review charts weekly to monitor for treatment plans updates done within 60 day timeframe. Compliance with code:7/27/16 |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Three of ten client records were reviewed on June 27, 2016, the facility failed to indicate that treatment was being provided to clients according to the individual treatment and rehabilitation plan.Client #3 was admitted on 4/14/16 and was still an active client as of the date of the licensing inspection. A preliminary treatment plan dated 4/14/16 indicated that client was to receive (1) individual therapy session and (2) group therapy sessions per week, however progress notes document the provision of group services only on the following dates:5/2/16, 5/3/16, 5/4/16, 5/9/16 and 5/18/16Client #7 was admitted on 8/7/15 and discharged on 10/29/15. A preliminary treatment plan dated 8/7/15 and a comprehensive treatment plan dated 9/3/15 indicate that the client was to receive (1) individual therapy session and (2) group therapy sessions per week, however progress notes document the provision of group services only on the following dates:8/9/15, 8/12/15, 8/26/15, 9/2/15, 9/9/15, 9/10/15, 10/1/15, 10/21/15 and 10/22/15Client #8 was admitted on 12/24/15 and discharged on 2/11/16. A preliminary treatment plan dated 1/23/16 indicated that client was to receive (1) individual therapy session and (2) group therapy sessions per week, however progress notes document the provision of group services only on the following dates:1/4/16, 1/13/16, 1/20/16 and 2/10/16This information was reviewed with facility staff.
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Plan of Correction
Director will ensure client#3,#7 and #8 receive (1)individual session and(2)groups weekly in adherence to days and times for service as indicated on the treatment plan. All clients at Erie OP will be provided treatment according to treatment plan. Any clients missing sessions or groups will receive follow up calls to reschedule sessions and groups within the week of scheduled service to have service provided. Clinical supervisor and lead counselor will monitor every client service to ensure adherence to days and times for service as indicated on the treatment plan. Documentation for services will be filed daily into charts to reflect services by counselors. |
709.93(a) 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:
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Observations
Ten client records were reviewed on June 27, 2016, the facility failed to ensure that there was a complete client record in nine of ten client records.Client #1 was admitted on 2/17/16 and was still an active client as of the date of the licensing inspection. The facilty failed to include in client #1's record, the record of service. A review of client #1's record showed that the client received eighteen individual sessions and twenty-eight group sessions. Client #2 was admitted on 1/26/16 and was still an active client as of the date of the licensing inspection. The facilty failed to include in client #2's record, the record of service. A review of client #2's record showed that the client received twelve individual sessions and thirty-two group sessions. Client #3 was admitted on 4/14/16 and was still an active client as of the date of the licensing inspection. The facilty failed to include in client #3's record, the record of service. A review of client #3's record showed that the client received seven individual sessions and fifteen group sessions. Client #4 was admitted on 1/4/16 and was still an active client as of the date of the licensing inspection. The facilty failed to include in client #4's record, the record of service. A review of client #4's record showed that the client received five individual sessions and fourteen group sessions. Client #5 was admitted on 2/10/16 and was still an active client as of the date of the licensing inspection. The facilty failed to include in client #5's record, the record of service. A review of client #5's record showed that the client received eight individual sessions and twenty-eight group sessions. Client #6 was admitted on 11/16/15 and was discharged on 1/4/16. Record of Service was not fully documented in client #6's chart. Only record of service entries are for the month of November for the following dates: 11/16/15, 11/17/15, 11/24/15, 11/25/15 and 11/30/15.Additionally, there was no discharge summary or follow up documented in client #'6 chart. Client #7 was admitted on 8/7/15 and was discharged on 10/29/15. The facility failed to document a follow-up.Client #8 was admitted on 12/24/15 and was discharged on 2/11/16. Record of Service was not documented in client chart.Client #10 was admitted on 9/7/15 and was discharged on 11/18/15. Record of Service was not fully documented in client chart, and a review of progress notes indicated the provision of eight individual and seventeen group counseling sessions.This information was reviewed with facility staff.
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Plan of Correction
Records of service will be put in all existing member charts to identify the 1)type of service provided, 2)the date service was provided, 3)counselor initial who provided the service, 4)explanation of missed services. Records of service will be put into charts for clients #1,#2,#3,#4,#5 immediately 6/28/16 and completed. Director will initiate facility procedure to ensure records of service are placed in members charts moving forward. The process of placing records of service into charts will begin at admission. Clinical supervisor and lead counselors will monitor charts daily to ensure the services provided match what is documented on the record of service.
Compliance with code:8/15/2016 |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
A physical plant inspection was conducted on June 27, 2016. The facility did not display the correct hours of facility operation. Hours of operation were changed in May 2016 but facility signage did not reflect these changes as of the date of the inspection.These findings were reviewed with facility staff.
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Plan of Correction
Director will create new facility signage to reflect current hours of operation. New facility signage reflects the hours of 8:00am -9:00pm M-Thursday and 9:00-5:00pm Friday and Saturday effective immediately. Compliance with code: 7/22/2016 |