INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 14, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of 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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704.7(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
Based on a review of personnel records, the facility failed to ensure that each counselor met the educational qualifications for the position in one of two applicable personnel records reviewed.
Employee #4 was hired as a counselor on February 16, 2021. At the time of the hire, the employee met the experiential requirements; however, the employee had a Bachelor ' s degree in General Arts, which is a non-qualifying degree for the position of counselor.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Employee #4 title will change to counselor assistant . Clinical Supervisor will supervise Employee #4 on a weekly basis and more if necessary. Clinical supervisor will review and sign off on all documentation. Employee #4 will prepare to take PCB, CADC test within the next year. Future resumes will be reviewed by HR and Facility prior to interviews |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document a dated signature of client on release of information forms in five of seven client records reviewed.
Client #1 was admitted on May 10, 2021 and was active at the time of inspection. There were release of information forms to a government agency, a transportation service, a urinalysis laboratory, a funding source, and an emergency contact, all signed and dated by the client on June 18, 2021. However, the dated signature of the witness on all of the release forms was documented on May 10, 2021, which was prior to the client's signature.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection. A release of information form to a government agency was signed and dated by staff on April 8, 2021; however, the dated signature of the client was not documented. Additionally, there were release of information forms to a government agency, a transportation service, a urinalysis laboratory, a funding source, and an emergency contact, all signed and dated by the witness on April 16, 2021; however, none of the forms documented the dated signature of the client.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection. There were release of information forms to a government agency, a transportation service, a urinalysis laboratory, a funding source, and an emergency contact, all signed and dated by the witness on May 3, 2021; however, none of the forms documented the dated signature of the client.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021. There were release of information forms to a government agency, a transportation service, and a urinalysis laboratory, all signed and dated by the witness on March 9, 2021; however, none of the forms documented the dated signature of the client.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021. There were release of information forms to a government agency, a transportation service, a urinalysis laboratory, a funding source, and an emergency contact, all signed and dated by the witness on April 19, 2021; however, none of the forms documented the dated signature of the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all new intakes will take place on site. At that time clients will sign and date all release of information forms. Clinical Supervisor will audit all files for accuracy. During the on site individual sessions Clients 1,2,3,4 and 7 will sign all release forms.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by clients that they had been informed of their right to retain civil rights and liberties except as provided by statute in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all new intakes will take place on site. At that time clients will sign and date Client Bill of Rights forms. Clinical Supervisor will audit all files for accuracy. During the on site individual sessions Clients 2,3,4 and 7 will sign all release forms. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by clients that they had been informed of their right that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all new intakes will take place on site. At that time clients will sign and date Client Bill of Rights forms. Clinical Supervisor will audit all files for accuracy. During the on site individual sessions Clients 2,3,4 and 7 will sign all release forms. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by clients that they had been informed of their right to inspect their own records in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all new intakes will take place on site. At that time clients will sign and date the ackmowledgement that they have the right to inspect their own records. Clinical Supervisor will audit all files for accuracy. During the on site individual sessions Clients 2,3,4 and 7 will sign all release forms. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by clients that they had been informed of their right to appeal a decision limiting access to their records to the director in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all new intakes will take place on site. At that time clients will sign and date acknowledgement that they have been informed of their right to appeal a decision limiting access to their records to the director. Clinical Supervisor will audit all files for accuracy. During the on site individual sessions Clients 2,3,4 and 7 will sign forms. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by clients that they had been informed of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in four of five client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all new intakes will take place on site. At that time clients will sign and date acknowledgement that they have been informed of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their record. Clinical Supervisor will audit all files for accuracy. During the on site individual sessions Clients 2,3,4 and 7 will sign all release forms. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to include documentation of the written acknowledgement by clients that they had been informed of their right to submit rebuttal data or memoranda to their own records in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all new intakes will take place on site. At that time clients will sign and date acknowledgement that they have been informed of their right to submit rebuttal data or memoranda to their own records. Clinical Supervisor will audit all files for accuracy. During the on site individual sessions Clients 2,3,4 and 7 will sign all release forms. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of the disclosure to the client of criteria for admission, treatment, completion and discharge in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all new intakes will take place on site. At that time clients will sign and date documentation of the disclosure of criteria for admission, treatment, completion and discharge. Clinical Supervisor will audit all files for accuracy. During the on site individual sessions Clients 2,3,4 and 7 will sign all release forms |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project's policies in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all intakes and evaluations will be done on site. At that time all clients will sign documentation of orientation to the project's policies. Clinical Supervisor will audit all records to assure accuracy. Clients 2,3,4, and 7 will complete this documentation during their on site individual sessions. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project's hours of operation in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all intakes and admissions will take place on site. At that time clients will sign and date documentation of orientation to the project's hours of operation. Clinical supervisor will audits all charts for accuracy. Clients 2,3,4 and 7 will sign this document during their individual session. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project's fee schedule in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all intakes and admissions will take place on site. At that time clients will sign and date documentation of orientation to the project's fee schedule. Clinical supervisor will audit all charts for accuracy. Clients 2,3,4 and 7 will sign this document during their individual session. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project's services provided in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all intakes and admissions will take place on site. At that time clients will sign and date documentation of orientation to the project's services. Clinical supervisor will audit all charts for accuracy. Clients 2,3,4 and 7 will sign this document during their individual session. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of the client's consent to treatment in four of five applicable client records reviewed.
Client #2 was admitted on April 16, 2021 and was active at the time of inspection.
Client #3 was admitted on May 3, 2021 and was active at the time of inspection.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective July 6, 2021 all intakes and admissions will take place on site. At that time clients will sign and date documentation of consent to treatment. Clinical supervisor will audit all charts for accuracy. Clients 2,3,4 and 7 will sign this document during their individual session. |
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, the facility failed to maintain a complete client record on an individual, which is to include case consultation notes in two out of two applicable client records reviewed.
Client #5 was admitted on December 8, 2020 and was discharged on April 30, 2021.
Client #6 was admitted on January 7, 2021 and was discharged on May 13, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be trained during staff meeting weekly on documentation including but not limited to case consultations. Clinical Supervisor and Facility will audit charts on a daily basis to assure documentation is in the charts. Individual coaching will be given to staff members as needed. |
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, the facility failed to maintain a complete client record on an individual, which is to include follow-up information in four of four applicable client records reviewed.
Client #4 was admitted on March 9, 2021 and was discharged on May 21, 2021.
Client #5 was admitted on December 8, 2020 and was discharged on April 30, 2021.
Client #6 was admitted on January 7, 2021 and was discharged on May 13, 2021.
Client #7 was admitted on April 19, 2021 and was discharged June 1, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical staff will be trained during staff meeting weekly on documentation including but not limited to follow-up information. Discharged clients will be tracked via discharge spreadsheet and follow up questionnaire will be completed with discharged clients by front desk staff within the first 30 days and given to facility director for approval. |