INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 1, 2018 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:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure that both the employee and the supervisor has input with the employee's written individual training plan in records, #1, 3 and 6. The supervisor did not sign or date the training plan.
Employee #1 was hired on 03/27/17 as the Facility Director.
Employee #3 hired 02/13/17 as a counselor.
Employee #6 hired 12/19/16 as a counselor.
The findings were reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Annually and at time of hire Human Resource Specialist will assure all employees will complete an individual training plan to include input by both the employee and their supervisor. This plan will be signed by both the employee and supervisor to adhere to 704.11(b)(1) and 704.11 Facility Director will audit personnel files quarterly to assure Individual Treatment Plans are complete.
Employee #1 had previous training plan signed off by Area Manager on 10-1-18
Employee #2 Facility Director added input to the individual training plan
Employee #3 Facility Director added input to the individual training plan |
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 the facility failed to ensure that employee #3 obtained the required 4 hours of TB/STD.
Employee #3 was hired on 02/13/17 as a counselor.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Erie Outpatient staff will be in compliance with mandatory Communicable Disease trainings. The trainings will be adequately documented and reflected in the personnel records of employees.
All new employees hired at Erie Outpatient will engage in a staff development program with the Human Resource Specialist that meets the general training requirements.
Employee #3 will complete the Department approved TB/STD training and provide documentation upon completion. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Based on a review of administrative paperwork and an interview with the Facility Director, the facility failed to notify the Department within 90 days of the occurrence of change in ownership.
The facility was purchased April 5, 2017 by GEO Group, Inc.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Ownership and Business Management Forms were submitted to the Department by GEO Corporate Offices on August 2018 |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of the facility's staff personnel records, the facility failed to ensure that a written annual staff performance evaluation was completed for each staff.
Employee #3 hired 02/13/17
Employee #5 hired 02/04/17
Employee #6 hired 12/16/16
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will ensure that performance evaluations are completed on the hire date of each employee annually.
Each employees hire date will be added to a spreadsheet on computer of facility director. These dates will be added to the calander to alert facility director 2 weeks in advance of due date of the performance evaluation.
Employee #3 was hired on 2/13/17. Facility Director completed staff performance evaluation on 4/9/18
Employee #5 was hired on 2/4/18. Facility Director completed performance evaluation on 4/9/18.
Employee #6 was hired on 12/16/16. Facility Director completed performance evaluation on 4/9/18 |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on direct observation by DDAP staff the facility failed to secure hard copies of client records within locked storage containers when not in use.
DDAP staff observed a counselor meeting with a client in the counselor's office where client identifying information was lying about the office. In addition, DDAP staff observed a client who had a key to the counselor's office where client records were stored. The client obtained the key from the counselor who was in the group room. The client was unsupervised when they entered the counselor's office that had identifying client records.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director will assure that all clinical staff attend the Confidentiality trainings at BHTEN within the next six months.
Ongoing confidentiality training will be conducted by Clinical Supervisor with Erie Outpatient staff during staff meetings. These trainings will be documented with a staff agenda and a sign in sheet.
Counselor who violated the client's confidentiality and gave key to client is no longer an employee at Erie Outpatient. Staff were informed that keys are not to be given to clients at anytime. It was reiterated that all client records are to be locked in the chart room and there is to be no client identifying information when a client is in the office with the counselors. |
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 the facility's "Mandatory Reporting" policies 9.1-9.5, the facility exceeds 42 CFR what is reportable.
The "Mandatory Reporting" policy indicates the following:
9.2 Credible Threat- "Notification of the target victim if contact information is available."
9.4 Vulnerable Adult Abuse or Neglect- "Notification to the vulnerable adult abuse/neglect hotline. The Facility Director shall complete and submit an Immediate Notification report to applicable Bureau of Community Corrections (BCC), Parole/Probation Department, Community Behavioral Health (CBH) and Department of Drugs and Alcohol Programs (DDAP.)"
This policy violates the restrictions of 42 C.F.R.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Facility Director will revise policy to come into compliance with the restrictions of 42 C.F.R. and submit the policy to the Area Manager for approval.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
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 must 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 the facility failed to document the information to be disclosed on client consents to release.
The consent to release form did not document what client information was to be disclosed. This was observed in the following client records:
Client #1 :
DOC dated 07/12/18
Parole dated 07/12/18
(2) Medical Labs dated 07/12/18
Funder dated 07/12/18
Emergency Contact dated 07/12/18
Agency dated 07/12/18
Client #3
Parole dated 06/28/18, "other" was checked but the information to be released wasn't documented.
Emergency Contact 06/28/18, "other" was checked but the information to be released wasn't documented.
Client #4
DOC dated 06/20/18, "other" was checked but the information to be released wasn't documented.
Parole dated 06/20/18, "other" was checked but the information to be released wasn't documented.
Medical Lab 06/20/18, "other" was checked but the information to be released wasn't documented.
Client #6
Funder dated 08/28/17
Client #8
Parole dated 02/06/18, "other" was checked but the information to be released wasn't documented.
DOC dated 02/08/18, "other" was checked but the information to be released wasn't documented.
(2) Medical Labs dated 02/08/18, "other" was checked but the information to be released wasn't documented.
Emergency Contact dated 02/08/18, "other" was checked but the information to be released wasn't documented.
Funder dated 02/08/18, "other" was checked but the information to be released wasn't documented.
Client #9
DOC 10/17/17
Client #10
DOC 08/21/17, "other" was checked but the information to be released wasn't documented.
Parole 08/21/17, "other" was checked but the information to be released wasn't documented.
Lab 08/21/17, "other" was checked but the information to be released wasn't documented.
Emergency Contact 08/21/17, "other" was checked but the information to be released wasn't documented.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Erie Outpatient staff will participate in state mandated trainings on Confidentiality within 6 months if they have not already done so. Director and Clinical Supervisor will conduct in house trainings to educate staff on how to complete releases of information forms correctly during staff meeting on 10/12/18 and ongoing. These trainings will include but not be limited to the information that can and cannot be disclosed. The line for other will be removed from the form and only added if needed. Clinical supervisor will oversee intake documentation to ensure adherence to PA Code 255.5 is being followed.
Clients #1,3,4,6,8,9 and 10
Client #1 & #4 - discharged |
709.28 (c) (6) 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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records the facility failed to document the expiration date.
Client #1 :
DOC dated 07/12/18
Parole dated 07/12/18
(2) Medical Labs dated 07/12/18
Funder dated 07/12/18
Emergency Contact dated 07/12/18
Agency dated 07/12/18
Client #4
DOC dated 06/20/18
Parole dated 06/20/18.
Medical Lab 06/20/18
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Erie Outpatient staff will participate in state mandated trainings on Confidentiality within 6 months if they have not already done so. Director and Clinical Supervisor will conduct in house trainings to educate staff on how to complete releases of information forms correctly during staff meeting on 10/12/18 and ongoing. These trainings will include but not be limited to assurance that the expiration date is filled in on releases. Clinical supervisor will oversee intake documentation to ensure adherence to PA Code 255.5 is being followed.
Client #1 & #4 - discharged
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records the facility failed to document that client's were offered a copy of the consents.
This was observed in the following client files:
Client #1 :
DOC dated 07/12/18
Parole 07/12/18
(2) Medical Labs dated 07/12/18
Funder dated 07/12/18
Emergency Contact dated 07/12/18
Agency dated 07/12/18
Client #3
DOC dated 06/28/18
Parole dated 06/28/18.
Emergency Contact 06/28/18
Funder 06/28/18
Client #4
DOC dated 06/20/18
Funder dated 06/20/18
Client #6
Funder dated 08/28/17
Lab 08/28/17
Client #10
DOC 08/21/17
Parole 08/21/17
Lab 08/21/17,.
Emergency Contact 08/21/17
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Erie Outpatient staff will participate in state mandated trainings on Confidentiality within 6 months if they have not already done so. Director and Clinical Supervisor will conduct in house trainings to educate staff on how to complete releases of information forms correctly during staff meeting on 10/12/18 and ongoing. These trainings will include but not be limited to assurance that the client's are offered a copy of the releases and that the importance in checking off it they accept or refuse a copy. Clinical supervisor will oversee intake documentation to ensure adherence to PA Code 255.5 is being followed.
Client #1,3,4,6,10 are discharged |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
A review of the facility's "Critical Incidents and Reporting" policy #1000.09 revealed that the facility did not have a policy or procedure in place to respond to a physical or sexual assault.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will revise policy to come into compliance with the Critical Incidents on reporting physical and sexual assaults and submit policy to Area Manager.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
A review of the facility's "Critical Incidents and Reporting" policy #1000.09 revealed that the facility did not have a policy or procedure in place to respond to selling or use of illicit drugs on the premises
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will revise policy to come into compliance with the Critical Incidents on selling or the use of illicit drugs on the premises. The policy will be given to Area Manager for review and approval.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
A review of the facility's "Critical Incidents and Reporting" policy #1000.09 revealed that the facility did not have a policy or procedure in place to respond to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will revise policy 1000.09 to come into compliance with the Critical Incidents on the response to death or serious injury due to trauma, suicide, medication error or unusual circumstances when know by the facility, for ambulatory services. The policy will be given to Area Manager for review and approval.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
A review of the facility's "Critical Incidents and Reporting" policy #1000.09 revealed that the facility did not have a policy or procedure in place to respond to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will revise policy to come into compliance with the Critical Incidents Policy on responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. The policy will be given to Area Manager for review and approval.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
A review of the facility's "Critical Incidents and Reporting" policy #1000.09 revealed that the facility did not have a policy or procedure in place to respond to theft, burglary, break-in or similar incident at the facility.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will revise policy to come into compliance with the Critical Incidents Policy on respo0nse to theft, burglary, break-in or similar incident at the facility. The policy will be given to Area Manager for review and approval.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
A review of the facility's "Critical Incidents and Reporting" policy #1000.09 revealed that the facility did not have a policy or procedure in place to respond to event at the facility requiring the presence of police, fire or ambulance personnel.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will revise policy to come into compliance with the Critical Incidents Policy on the event at the facility requiring the presence of police, fire or ambulance personnel. The policy will be given to Area Manager for review and approval.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
A review of the facility's "Critical Incidents and Reporting" policy #1000.09 revealed that the facility did not have a policy or procedure in place to respond to fire or structural damage to the facility.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will revise policy to come into compliance with the Critical Incidents Policy on the response to fire or structural damage in the facility. The policy will be given to Area Manager for review and approval.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
A review of the facility's "Critical Incidents and Reporting" policy #1000.09 revealed that the facility did not have a policy or procedure in place to respond to outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will revise policy to come into compliance with the Critical Incidents Policy on the response to outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. The policy will be given to Area Manager for review and approval.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
A review of the facility's "Critical Incidents and Reporting" policy #1000.09 revealed that the policy does not address ongoing monitoring of the corrective action plan.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will revise policy to come into compliance with the Critical Incidents Policy on addressing ongoing monitoring of the corrective action plan. The policy will be given to Area Manager for review and approval.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
A review of the facility's "Critical Incidents and Reporting" policy #1000.09 revealed that the policy does not address the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
The finding was reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will revise policy to come into compliance with the Critical Incidents Policy on the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with the State and Federal confidentiality laws. The policy will be given to Area Manager for review and approval.
Upon approval of policy Facility Director will review the revised policy with the staff during Staff Meeting. This will be documented via a sign in sheet and agenda.
Revised policy will be placed in the Policy and Procedure Binder and the binder will be kept where it can be accessed by all staff. |
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
Based on a review of ten client records, the facility failed to develop an individual treatment plan with a client in client records, #3 and 4.
Client #3 admitted 06/28/18
Client #4 admitted 06/20/18
The findings were reviewed with facility staff the day of the licensing inspection.
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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 their perspective caseloads. Clinical supervisor will review and sign off that charts have been reviewed and treatment plans are in all charts.
Client #3 and #4 will have treatment plan developed immediately |
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
Based on a review of four client records the facility failed to review and update treatment plans every 60 days in client records, #2, 9 and 10.
Client #2's treatment plan was updated 05/04/18, the treatment plan did not address the goals from the previous treatment plan dated 04/27/18. Additionally, there were no treatment plan updates after this date and this client is still active in treatment.
Client #9's treatment plan was updated 12/30/17, the treatment plan did not address the goals from the previous treatment plan.
Client #10's treatment plan dated 02/02/18 was late and is the only one documented since 07/24/17. Additionally, this treatment plan does not address goals from the previous treatment plan.
The findings were reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
A spreadsheet with each client's treatment plan updates due date will be created and monitored by the clinical supervisor to ensure timely completion of the updates. Clinical staff will be given email alerts indicating when a plan is due for clients on their perspective caseloads. Clinical supervisor will review and sign off that charts have been reviewed and updates are in all charts. Clinical Supervisor will conduct training during staff meetings on the correct way to complete treatment plans and updates. This training will include but not be limited to including addressing goals from the previous treatment plan.
Clinical supervisor will review charts weekly to monitor completion of treatment plans and treatment plan updates within the time frames regulated |
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
Based on a review of ten client records the facility failed to maintain a complete client record in client records, #2, 3, 4, 5, 6, 7, 8 and 10.
A review of client records revealed the following:
Client #2 was admitted on 3/28/18 and the last session was documented on 5/25/18. No documentation re-engaging the client back into treatment. Additionally, there were no case consultation documented since admission.
Client #3 was admitted on 6/28/18 and their last session was documented on the same day. No documentation re-engaging the client back into treatment.
Client #4 was admitted on 6/20/18 and their last session was documented on the same day. There was no documentation that the facility was re-engaging the client back into treatment
Client #5 was admitted on 6/4/18 and the last session was documented on 6/28/18, there was no progress note to address re-engaging this client in treatment.
Client #6 was discharged on 1/31/18 and the facility failed to document follow-up since discharge.
Client #7 was discharged on 4/2/18 and the facility failed to document follow-up since discharge.
Client #8 was discharged on 3/7/18 and the facility failed to document follow-up since discharge.
Client #10 was admitted on 7/19/17 and discharged 2/23/18. The After-Care Plan was not signed or dated, and the case consultation was not completed until the day of the client's discharge.
The findings were reviewed with facility staff the day of the licensing inspection.
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Plan of Correction
Facility Director will initiate facility procedure to ensure records of service are completed.
Upon daily review of charts, Clinical Supervisor will assure that record of service is complete and services provided match what is documented on the record of service. Clinical Supervisor will assure documentation is in the clients' chart with counselors attempts to re-engage clients if client did not show up for a scheduled appointment. Case consultations will be conducted quarterly during weekly team meetings with clinical staff. A spreadsheet will be created by clinical supervisor with each client's due date for case consultations and follow ups after discharge. There will be an email to alert counselors when these case consults and follow ups are due.
Client records for Client 2, 3, 4, 5, 6, 7, 8, and 10 will be updated with all services rendered.
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