INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18, 2011 through April 20, 2011 by staff from the Division of Drug and Alcohol Program Licensure. 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 and a plan of correction is due on May 24, 2011.
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Plan of Correction
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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 and an interview with the facility director, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in four of sixteen records reviewed. The findings include:From April 19, 2011 through April 20, 2011, sixteen records were reviewed for informed and voluntary consent. The facility released information without the client's consent in client records # 3, 4 and 6.Client record # 31. Contained a copy of the client's biopsychosocial evaluation that was faxed by the facility on 1/31/11 to a government agency; however, the facility did not document a signed consent from the client to release the biopsychosocial evaluation. In addition, the information released exceeds that which is permissible under 4 Pa. Code 255.5.Client record # 41. Contained a report that indicated that a sample of the client ' s urine was released on 3/24/11 by the facility to a diagnostic laboratory; however, the facility did not document a signed consent from the client to release the urine sample.2. Contained an Eligibility Verification System form in which the facility released information about the client on 10/21/10 to a funding source. However, the facility did not document a signed consent from the client to release the information. 3. Contained a copy of a letter that was sent by the facility on 3/24/11 to a person verifying that the client has been in treatment; however, the facility did not document a signed consent from the client to release the letter. Client record # 61. Contained a copy of the client's medical history, drug and alcohol history, personal history, psychosocial evaluation, and TDAT Initial Intake Form that were faxed by the facility on 1/13/11 to a government agency. However, the facility did not document a signed consent from the client to release the information. In addition, the information released exceeds that which is permissible under 4 Pa. Code 255.5.An interview with the facility director on April 20, 2011 confirmed that the facility release information about clients # 3, 4 and 6 without a signed consent from the clients.
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Plan of Correction
Plan of Correction:
MinSec Erie Outpatient is now utilizing an Electronic Client Chart. Relevant Consent Forms will be printed and signed during the Intake Process.
All clinical staff will be trained in identifying the Consent Forms that are needed for the specific client's chart. This training will be facilitated by the Clinical Supervisor on 6/15/11.
The Federal and State Confidentiality Regulations (42 CFR Part II and PA code 255.5) regulating records disclosure will be reviewed and explained as a part of the training.
Any client information released must be accompanied with the appropriate consent form signed by the client and staff. The documentation will be reviewed by the Program Director or Clinical Supervisor and filed in the client's chart after approval.
Responsible Employee:
Clinical Supervisor
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records and an interview with the facility director, the facility documented consent to release information forms that allowed for the release of client information that exceeded which is permissible under 4 Pa. Code subsections 255.5 (b), in eleven of sixteen client records reviewed.The findings include:From April 19, 2011 to April 20, 2011, sixteen records were reviewed for consent to release information forms. The facility documented consent to release information forms that allowed for the release of client information that exceeded which is permissible under 4 Pa. Code subsections 255.5(b) in client records # 1, 2, 5, 7, 8, 9, 10, 11, 12, 14, and 16.Client record # 11. One consent to release information to a funding source dated 1/3/11 was completed allowing the release of discharge summary.Client record # 21. One consent to release information to a funding source dated 1/5/11 was completed allowing the release of discharge summary.Client record # 51. One consent to release information to a funding source dated 11/5/10 was completed allowing the release of discharge summary.Client record # 71. One consent to release information to a funding source dated 10/14/10 was completed allowing the release of discharge summary.Client record # 81. One consent to release information to a funding source dated 11/3/10 was completed allowing the release of discharge summary.Client record # 91. One consent to release information to a funding source dated 9/7/10 was completed allowing the release of discharge summary.Client record # 101. One consent to release information to a funding source dated 7/21/10 was completed allowing the release of discharge summary.2. Two consents to release information to a government agency dated 7/21/10 were completed allowing the release of discharge summary.Client record # 111. Two consents to release information to a funding source dated 7/7/10 were completed allowing the release of discharge.2. Two consents to release information to a government agency dated 7/7/10 were completed allowing the release of discharge summary.Client record # 121. One consent to release information to a funding source dated 7/28/10 was completed allowing the release of discharge summary.Client record # 141. One consent to release information to a funding source dated 9/1/10 was completed allowing the release of discharge summary. Client record # 161. One consent to release information to a funding source dated 7/23/10 was completed allowing the release of discharge summary. An interview with the facility director on April 20, 2011 confirmed that client records # 1, 2, 5, 7, 8, 9, 10, 11, 12, 14, and 16 contained consent to release information that exceeded which is permissible under 4 Pa. Code subsections 255.5 (b).
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Plan of Correction
Plan of Correction:
All clinical staff will be trained in identifying the Consent Forms that are needed for the specific client's chart. This training will be facilitated by the Clinical Supervisor on 6/15/11.
The Federal and State Confidentiality Regulations (42 CFR Part II and PA code 255.5) regulating records disclosure will be reviewed and explained as a part of the training.
The electronic clinical chart was reviewed by the Quality Assurance Director for appropriate release of discharge summary on 5/05/11 and the necessary revisions were made.
The consent to release forms will be reviewed by the Program Director or designee during Clinical Chart audits.
Responsible Employee:
Program Director
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709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document the purpose of disclosure on the consent to release information forms in nine of sixteen client records reviewed.The findings include:From April 19, 2011 to April 20, 2011, sixteen records were reviewed for consent to release information forms. The facility failed to document the purpose of disclosure on the consent to release information forms in nine of sixteen client records reviewed, specifically, records # 1, 2, 5, 7, 8, 9, 10, 11 & 12.Client record # 11. One consent to release information to a funding source dated 1/3/11 did not include the purpose of disclosure.Client record # 21. One consent to release information to a funding source dated 1/5/11 did not include the purpose of disclosure.Client record # 51. One consent to release information to a funding source dated 11/5/10 did not include the purpose of disclosure.Client record # 71. One consent to release information to a funding source dated 10/14/10 did not include the purpose of disclosure.Client record # 81. One consent to release information to a funding source dated 11/3/10 did not include the purpose of disclosure.Client record # 91. One consent to release information to a funding source dated 9/7/10 did not include the purpose of disclosure.Client record # 101. One consent to release information to a funding source dated 7/21/10 did not include the purpose of disclosure.2. Two consents to release information to a government agency dated 7/21/10 did not include the purpose of disclosure.Client record # 111. Two consents to release information to a funding source dated 7/7/10 did not include the purpose of disclosure.2. Two consents to release information to a government agency dated 7/7/10 did not include the purpose of disclosure.Client record # 121. One consent to release information to a funding source dated 7/28/10 did not include the purpose of disclosure.An interview with facility director on the same day confirmed that client records # 1, 2, 5, 7, 8, 9, 10, 11, and 12 did not include the purpose of disclosure.
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Plan of Correction
Plan of Correction:
All clinical staff will be trained in identifying the Consent Forms that are needed for the specific client's chart. This training will be facilitated by the Clinical Supervisor on 6/15/11. The Federal and State Confidentiality Regulations (42 CFR Part II and PA code 255.5) regulating records disclosure will be reviewed and explained as a part of the training.
The electronic clinical chart was reviewed by the Quality Assurance Director for the appropriate purpose of the disclosure on all consent to release information forms on 5/05/11 and the necessary revisions were made.
The consent to release forms will be reviewed by the Program Director or designee during random Clinical Chart audits.
Responsible Employee:
Program Director
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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 records and an interview with the facility director, the facility failed to document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, negative factors, and/or counselor's conclusions/impressions in 13 of 16 records reviewed, specifically,client records # 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 13, 14, and 16. In addition, the facility failed to document a psychosocial evaluation in one of sixteen records reviewed.The findings include:From April 19, 2011 to April 20, 2011, sixteen client records were reviewed for psychosocial evaluations. The facility did not document a psychosocial evaluation in client record # 15. In addition, the facility did not document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, negative factors, and/or counselor's conclusions/impressions in client records # 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 13, 14, and 16.The facility's policy titled: "Treatment Management", states:"The Complete Psychosocial Assessment and the Master Treatment Plan will be completed within 30 days of admission."Also, the facility's policy titled: "Psychosocial Assessment", states: "Psychosocial evaluation including:1.Present and underlying issues.2.Problems not related or resolvable by substance abuse treatment 3.Strengths and personal qualities that will complement and facilitate treatment.4.Weaknesses and personal qualities that may interfere with or inhibit treatment.5.Support system.6.Preferred coping skills.7.General appearance and affect among staff and other clients.8.Conclusion made by assessor regarding the client's overall attitude about treatment, receptiveness to program goals, and willingness to participate."Client # 1 was admitted January 3, 2011. The psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, negative factors, and counselor's conclusion/impression.Client # 2 was admitted January 5, 2011. The psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, negative factors, and counselor's conclusion/impression. Client # 3 was admitted January 6, 2011. The psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, negative factors, and counselor's conclusion/impression.Client # 4 was admitted October 21, 2010. The psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, negative factors, and counselor's conclusion/impression.Client # 6 was admitted January 7, 2011. The psychosocial evaluation was completed on January 7, 2011, but it did not include an evaluation of the client's assets/strengths, support systems, and negative factors.Client # 7 was admitted October 14, 2010. The psychosocial evaluation was completed on October 14, 2010, but it did not include an evaluation of the client's assets/strengths, support systems, and negative factors.Client # 8 was admitted November 3, 2010. The psychosocial evaluation was completed on November 3, 2010, but it did not include an evaluation of the client's assets/strengths, support systems, and negative factors.Client # 9 was admitted September 7, 2010. The psychosocial evaluation was completed on September 16, 2010, but it did not include an evaluation of the client's assets/strengths, support systems, and negative factors.Client # 10 was admitted July 21, 2010. The psychosocial evaluation was not signed or dated and it did not include an evaluation of the client's assets/strengths, support systems, and negative factors.Client # 11 was admitted July 7, 2010. The psychosocial evaluation completed on July 7, 2010, but it include an evaluation of the client's assets/strengths, support systems, and negative factors.Client # 13 was admitted July 22, 2010. The psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, negative factors, and counselor's conclusion/impression.Client # 14 was admitted September 1, 2010. The psychosocial evaluation did not include an evaluation of the client ' s assets/strengths, support systems, negative factors, and counselor's conclusion/impression.Client # 16 was admitted July 23, 2010. The psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, negative factors, and counselor's conclusion/impression.An interview with the facility director on April 20, 2011 confirmed that the facility did not document a psychosocial evaluation in client record # 15. In addition, the facility did not document a psychosocial evaluation that included an assessment of the client's assets/strengths, support systems, negative factors, and/or counselor's conclusions/impressions in client records # 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 13, 14, and 16.This is a repeat citation. The facility was cited on April 8, 2009; April 15, 2008; August 8, 2006; and September 15, 2004 on psychosocial evaluations. The facility's Plan of Correction for the April 8, 2009 citation was as follows: "Psychosocial evaluations will include substantially more information and content with regards to client ' s assets and strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, the client ' s attitude toward treatment and the counselor ' s impression of the client. Responsible Employee: Program Director Director of Quality Assurance Methodology: A comprehensive training with a focus on Evaluation and Assessment per BDAP Policy 709.91(b)(6) will occur on Wednesday May 20th 2009. During this training, all clinical staff will be instructed on how to provide specific, individualized and comprehensive information with regards to all aspects of assessment including client assets and strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, the client ' s attitude toward treatment and the counselor's impressions. Program Director and Director of Quality Assurance will monitor the quality and completion of the Psychosocial Assessments monthly on an on-going basis. Completion Date: 5/20/09"The facility's Plan of Correction for the April 15, 2008 citation was as follows:"1. The Project Director will develop a new weekly schedule of documentation submission to ensure timeliness and the completion of all clinical documentation by 6/1/2008 2. The Project Director will update the current policy to ensure that goals for completion of psychosocial evaluations are realistic and corresponding with the standard by 5/30/2008. 3. The Project Director will establish a training curriculum for clinical staff to explain the new "schedule for documentation" by 6/17,2007. 4. The Program Director will monitor and uphold the new documentation system by collecting and acknowledging the submitted documentation on a weekly basis and will insure that monthly file reviews are conducted through the QA system."
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Plan of Correction
Plan of Correction:
There will be a review of the electronic psychosocial assessment via an in-service training. Strategies on the clinician assessing and documenting information received during the psychosocial process will be discussed. The training will be facilitated by the Quality Assurance Director. The date of the training will be on 6/22/11.
The quality of the Psychosocial Assessments will be monitored and reviewed upon completion by the Clinical Supervisor. The completion date for this process will be 6/29/11.
Responsible Employee:
Clinical Supervisor |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document an initial case consultation in eight of sixteen records reviewed.Also, based on a review of client records and an interview with the facility director, the facility failed to document a second case consultation in three of eight records reviewed.In addition, based on a review of client records and an interview with the facility director, the facility failed to document a case consultation in accordance with the facility ' s policy and procedures in two of eight records reviewed.The findings include:From April 19, 2011 to April 20, 2011, sixteen client records were reviewed for documentation of a case consultation. The facility did not document an initial case consultation in client records # 1, 2, 7, 10, 12, 13, 14 and 16. Also, the facility did not document a second case consultation in client records # 6, 9, and 11. In addition, the facility did not document a case consultation according to their policy and procedure in client records # 5 and 8.The facility's policy titled: "Treatment Management", states:"The Treatment Team will complete a case consultation on client every 60 days or as needed"Client # 1 was admitted January 3, 2011. Client # 1's record did not include documentation of an initial case consultation as of April 20, 2011.Client # 2 was admitted January 5, 2011. Client # 2's record did not include documentation of an initial case consultation as of April 20, 2011.Client # 5 was admitted November 5, 2010; however, the facility did not document a case consultation until February 8, 2011. Client # 6 was admitted January 7, 2011. The initial case consultation was completed on January 19, 2011; however, client # 6's record did not include documentation of a second case consultation as of April 20, 2011.Client # 7 was admitted October 14, 2010. Client # 7's record did not include documentation of an initial case consultation as of April 20, 2011.Client # 8 was admitted November 3, 2010; however, the facility did not document a case consultation until January 6, 2011. Client # 9 was admitted September 7, 2010. The initial case consultation was completed on October 5, 2010; however, client # 9's record did not include documentation of a second case consultation as of April 20, 2011.Client # 10 was admitted July 21, 2010. Client # 10's record did not include documentation of an initial case consultation as of April 20, 2011.Client # 11 was admitted July 7, 2010. The initial case consultation was completed on July 22, 2010; however, client # 11's record did not include documentation of a second case consultation as of April 20, 2011.Client # 12 was admitted July 28, 2010. Client # 12's record did not include documentation of an initial case consultation as of April 20, 2011.Client # 13 was admitted July 22, 2010. Client # 13's record did not include documentation of an initial case consultation as of April 20, 2011.Client # 14 was admitted September 1, 2010. Client # 14's record did not include documentation of an initial case consultation as of April 20, 2011.Client # 16 was admitted July 23, 2010. Client # 16's record did not include documentation of an initial case consultation as of April 20, 2011.An interview with the facility director on April 20, 2011 confirmed that the facility did not document an initial case consultation in client records # 1, 2, 7, 10, 12, 13, 14 and 16. Also, an interview with the facility director on the same day confirmed that the facility did not document a second case consultation in client records # 6, 9, and 11. In addition, another interview on the same day with the facility director confirmed that the facility did not document a case consultation according to their policy and procedure in client records # 5 and 8. This is a repeat citation. The facility was cited on April 15, 2008; June 26, 2007; and April 4, 2002 on case consultation.The facility's Plan of Correction for the April 15, 2008 citation was as follows: "1. The Project Director will develop a training curriculum to instruct clinical staff on "Effective Clinical Documentation" to insure that case consultations are accurate in their content and timely by 6/1/2008. 2. The Project Director will update the current policy to ensure that MinSec's [sic] policy for completing case consultations are realistic and corresponding with the standard by 5/30/2008. 3. The MinSec Training Institute will conduct a Clinical Inservice Training before 7/18,2008 in order to address inconsistencies and deficiencies in the client documentation practices. 4. The Program Director will monitor and uphold the new documentation system by collecting and acknowledging the accuracy and timeliness of submitted documents on a weekly basis and will insure that monthly file reviews are conducted through the QA system."
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Plan of Correction
Plan of Correction:
Case Consultation will be done for each client within sixty days of admission. Thereafter, case consults are held every 60 days or as necessary. The case consultation will be complete as a segment of the treatment plan review and treatment plan update process. The written case consultation will be submitted along with Master Treatment plan within 30 days for review by Program Director or Clinical Supervisor. The Treatment plan update and case consultation will be submitted within 60 days after completion of Master Treatment Plans and within every 60 days thereafter for review by Program Director or Clinical Supervisor.
Policy 709.24 Treatment Management will be reviewed during the clinical staff training on 06/08/15.
Responsible Employee:
Clinical Supervisor
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document an aftercare plan in two of five records reviewed. The findings include:On April 20, 2011, five records were reviewed for documentation of an aftercare plan. The facility did not document an aftercare plan in client records # 9 and 10. The facility's policy titled: "Aftercare", states:"Development: During the re-entry phase of treatment (the last 30 days), the primary counselor will make every attempt to involve appropriate persons and/or agencies prior to finalizing the client's aftercare planning process. The aftercare must be completed within 7 days of discharge and may be revised thereafter before discharge. Aftercare Plans are monitored for days post-discharge. " Client # 9 was admitted September 7, 2010 and was discharge December 9, 2010; however, client # 9's record did not include documentation of an aftercare plan as of April 20, 2011.Client # 10 was admitted July 21, 2010 and was discharge November 5, 2010; however, client # 10's record did not include documentation of an after care plan as of April 20, 2011.An interview with the facility director on April 20, 2011 confirmed that the facility did not document an aftercare plan in client records # 9 and 10.This is a repeat citation. The facility was cited on April 8, 2009; April 15, 2008; and August 8, 2006 on aftercare plans. The facility's Plan of Correction for the April 8, 2009 citation was as follows: "The MinSec Treatment Companies LLC policy on Aftercare Plans shall be revised to state that Aftercare Plans will only be completed on clients who have successfully completed the program. Responsible Employee: Director of Quality Assurance Program Director Clinical Supervisor Methodology: Closed charts will be reviewed by the Program Director and/or Clinical Supervisor prior to the Completion Certificate being signed by the Program Director. The request for the completion certificate must be accompanied by the Aftercare Plan and Discharge Plan. The Program Director and Director of Quality Assurance will monitor Aftercare Plan submissions on a monthly basis. Completion 5/20/09 "The facility's Plan of Correction for the April 15, 2008 citation was as follows:"1. The Project Director will develop a new weekly schedule of documentation submission to ensure timeliness and the completion of all clinical documentation by 6/1/2008. 2. The Program Director will monitor and uphold the new documentation system by collecting and acknowledging the timeliness of submitted documents on a weekly basis and will insure that monthly file reviews are conducted through the QA system."
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Plan of Correction
The Clinical Supervisor will review Minsec Treatment, LLC Policy 709.94D (Aftercare Policy) during the clinical staff meeting on 06/08/11.
Aftercare Plans must be submitted for review by Program Director prior to the Certificate of Completion being issued. This is to ensure that the proper documentation is being placed in the closed charts.
Responsible Employee:
Program Director
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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 an interview with the facility director, the facility failed to document follow-up information in eight of eight records reviewed.The findings include:From April 19, 2011 to April 20, 2011, eight records were reviewed for documentation of follow-up information. The facility did not document follow-up information in client records # 9, 10, 11, 12, 13, 14, 15, and 16.The facility's policy titled: "Follow-Up Procedure", states:"1. With client's written consent and within 30 days the primary counselor or the continuing care specialist will call the telephone number of the client.2. If no phone is available, a letter will be sent to the client at the last known address to check the client ' s post-treatment progress and encourage the client to contact MinSec if he/she is in need of further assistance."Client # 9 was admitted September 7, 2010 and was discharge December 9, 2010; however, client # 9's record did not include documentation of follow-up information as of April 20, 2011.Client # 10 was admitted July 21, 2010 and was discharge November 5, 2010; however, client # 10's record did not include documentation of follow-up information as of April 20, 2011.Client # 11 was admitted July 7, 2010 and was discharge October 7, 2010; however, client # 11's record did not include documentation of follow-up information as of April 20, 2011.Client # 12 was admitted July 28, 2010 and was discharge October 25, 2010; however, client # 12's record did not include documentation of follow-up information as of April 20, 2011.Client # 13 was admitted July 22, 2010 and was discharge December 12, 2010; however, client # 13's record did not include documentation of follow-up information as of April 20, 2011.Client # 14 was admitted September 1, 2010 and was discharge December 20, 2010; however, client # 14's record did not include documentation of follow-up information as of April 20, 2011.Client # 15 was admitted July 21, 2010 and was discharge November 5, 2010; however, client # 15's record did not include documentation of follow-up information as of April 20, 2011.Client # 16 was admitted July 23, 2010 and was discharge October 28, 2010; however, client # 16's record did not include documentation of follow-up information as of April 20, 2011.An interview with the facility director on April 20, 2011 confirmed that the facility did not document follow-up information in client records # 9, 10, 11, 12, 13, 14, 15, and 16.This is a repeat citation. The facility was cited on April 8, 2010; April 8, 2009; April 15, 2008; and June 26, 2007 on follow-up information.The facility's Plan of Correction for the April 8, 2010 citation was as follows:"Client follow up will be made on bi-weekly basis. A call will be placed to clients discharged within the prior two weeks. If the client is inaccessible via phone a letter will be mailed to the client's last known address. Responsible Employee: Clinical Assistant "The facility's Plan of Correction for the April 8, 2009 citations was as follows:"Follow-up information will be documented for all clients discharged from the facility, regardless of status of discharge. Responsible Employee: Program Director; Administrative Assistant Methodology: Follow up calls on all discharged clients will be completed by the Administrative Assistant effective Friday, April 24th 2009 per BDAP Policy 709.93(a)(11) Client Records. The Administrative Assistant will keep record of all follow up information in a separate log available to all staff. Program Director will monitor the completion of all Follow Up Calls in the follow Up Log on a monthly basis. Completion Date: 4/24/09 "
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Plan of Correction
Plan of Correction:
Follow-up information will be documented for all clients discharged from the facility, regardless of status of discharge. Follow up calls on all discharged clients will be completed by the Administrative Assistant weekly effective Monday, May 16, 2011 per BDAP Policy 709.93(a) (11) Client Records. The Administrative Assistant will keep record of all follow up information in a separate log available to all staff. The Program Director will monitor the completion of all Follow Up Calls in the follow Up Log on a Bi-weekly basis. Completion Date: 5/30/11.
Responsible Employee:
Administrative Assistant
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on review of client records and an interview with the facility director, the facility failed to comply with 55 Pa. Code Part III (relating to Medical Assistance Manual) in five of eleven client records reviewed for clients that receive medical assistance.The findings include:From April 19, 2011 to April 20, 2011, eleven client records were reviewed for documentation of a physician ' s signature on client treatment plans. A physician did not sign the individual treatment and rehabilitation plan in client records # 5 and 16. Also, a physician did not sign the treatment and rehabilitation plan update in client records # 5, 9, and 11. In addition, a physician did not sign the second treatment and rehabilitation plan update in client record # 8. The regulation at 55 Pa. Code Part III chapter 1223.52 section (a) subsection 6 (i) - (ii) specifies that "within 15 days following intake, the clinic's supervisory physician shall review and verify each patient's level of care assessment, psychosocial evaluation and initial treatment plan prior to the provision of any treatment beyond the 15th day following intake. The clinic's supervisory physician shall verify the patient's diagnosis. The clinic's supervisory physician shall sign and date the patient's level of care assessment, psychosocial evaluation, treatment plan and diagnosis in the patient's record. Payment will not be made for services provided within or beyond the 15th day following intake, without the clinic's supervisory physician's review and approval of the level of care assessment, psychosocial evaluation, treatment plan and determination of the patient's diagnosis. Sixty days following the date of the initial treatment plan and at the end of every 60-day period during the duration of treatment, the clinic's supervisory physician shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician. "Client # 5 was admitted November 5, 2010. The preliminary treatment and rehabilitation plan was completed November 5, 2010, the individual treatment and rehabilitation plan was completed December 5, 2010, and the treatment and rehabilitation plan update was completed February 8, 2011. Client # 5's record did not have documentation of a physician 's signature on the individual treatment and rehabilitation plan as well as the treatment and rehabilitation plan update as of April 20, 2011. Client # 8 was admitted November 3, 2010. The preliminary treatment and rehabilitation plan was completed November 3, 2010, the individual treatment and rehabilitation plan was completed December 2, 2010, the initial the treatment and rehabilitation plan update was completed January 28, 2011, and the second treatment and rehabilitation plan update was completed April 1, 2011. Client # 8's record did not have documentation of a physician's signature on the second treatment and rehabilitation plan update as of April 20, 2011. Client # 9 was admitted September 7, 2010 and was discharge December 9, 2010. The preliminary treatment and rehabilitation plan was completed September 7, 2010, the individual treatment and rehabilitation plan was completed October 5, 2010, and the treatment and rehabilitation plan update was completed November 23, 2010. Client # 9 ' s record did not have documentation of a physician ' s signature on the treatment and rehabilitation plan update as of April 20, 2011. Client # 11 was admitted July 7, 2010 and was discharge October 7, 2010. The preliminary treatment and rehabilitation plan was completed July 7, 2010, the individual treatment and rehabilitation plan was completed August 5, 2010, and the treatment and rehabilitation plan update was completed September 23, 2010. Client # 11's record did not have documentation of a physician ' s signature on the treatment and rehabilitation plan update as of April 20, 2011. Client # 16 was admitted July 23, 2010 and was discharge October 28, 2010. The preliminary treatment and rehabilitation plan was completed January 3, 2011 and the individual treatment and rehabilitation plan was completed January 31, 2011.. Client # 16's record did not have documentation of a physician ' s signature on the individual treatment and rehabilitation plan as of April 20, 2011.An interview with the facility director on April 20, 2011 confirmed that a physician did not sign the individual treatment and rehabilitation plan in client records # 5 and 16. Also, an interview with the facility director on the same day confirmed that a physician did not sign the treatment and rehabilitation plan update in client records # 5, 9, and 11. In addition, another interview with the facility director on the same day confirmed that a physician did not sign the second treatment and rehabilitation plan update in client records # 8.
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Plan of Correction
Plan of Correction:
MinSec Corporation actively interviewed and hired a consulting psychiatrist who will review treatment plans for MinSec Erie Outpatient clients. The psychiatrist assumed duties on 5/12/11. The psychiatrist will routinely screen treatment plans and offer his/her signature on treatment plans that meet internal quality assurance and external program licensure standards.
Responsible Employee:
Executive Medical Director.
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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
Based on a review of personnel records and a discussion with the clinical supervisor and the facility director, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training in two of three of ten personnel records reviewed. The findings include:Ten personnel records were reviewed on April 18, 2011. A minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training was required in ten personnel records. Staff # 7 is a counselor who was hired on 3/31/08. A minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training was required on or before 3/31/09. As of 4/18/11, there was no documentation in personnel record #7 of any TB/STD training. Staff # 9 is a support staff who was hired on 7/1/08. A minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training was required on or before 7/1/10. As of 4/18/11, there was no documentation in personnel record #9 of any HIV/AIDS or TB/STD training. Staff # 10 is a counselor who was hired on 3/15/10. A minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD training was required on or before 3/15/11. As of 4/18/11, there was no documentation in personnel record #10 of any HIV/AIDS training. During a discussion with the clinical supervisor and the facility director, they acknowledged that staff #7, 9 and 10 did not have the required trainings.
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Plan of Correction
Plan of Correction:
Minsec Erie Outpatient staff will be in compliance with the Mandatory Communicable Disease Training. On May 27th 201l, staff will be trained in TB/STB/Hepititis. On June 17th 2011 staff will be trained in HIV/Aids. The trainings will be adequately documented and reflected in the personnel records of employees.
All new employees hired at MinSec Erie Outpatient will be engage in a Staff development program that meets the general training requirements.
Responsible Employee:
Program Director
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records and a discussion with the clinical supervisor, the facility failed to ensure all counselors complete at least 25 clock hours of training annually in one of ten personnel records reviewed. The findings include:Ten personnel records were reviewed on April 18, 2011. Five of those personnel records were counselors. Four of those five counselors were employed for more than a full training year and were required to have completed at least 25 clock hours of training annually. The facility's training year is a calendar year. The training year reviewed was from January 1, 2010 through December 31, 2010. Staff #7 is a counselor who was hired on 3/31/08 and is required to have completed at least 25 clock hours of training for the 2010 facility training year. As of 4/18/11, personnel record #7 only had six clock hours of training documented for the facility's 2010 training year. During a discussion with the clinical supervisor, this was acknowledged.
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Plan of Correction
Plan of Correction:
MinSec Erie Outpatient Program Director will review the treatment division training plan and each clinical staff member's individual training plan. Upon review, trainings will be selected and implemented for each staff person. Each staff member will have at a minimum of 25 clock hours from 1/1/2011 to 12/31/11.
By the first day of January of each year, the Program Director will complete an individual training plan for each counselor. The training plan will be reviewed with the counselor and the counselor will be solicited for input on trainings. The Program Director will ensure that counselors attend mandatory trainings per regulatory requirements. Training clock hours scheduled will not be less than 25 for each staff member.
Responsible Employee:
Program Director |