INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2017, 2017 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 to be not 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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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
Seven client records were reviewed on July 11, 2017. The facility failed to document a valid consent to release information form in client records, #1, 4, 5, 6 & 7.
Client #1 was admitted on 1/19/17 and was an active client at the time of the licensing inspection. A consent to release to a government agency, dated 1/3/17, permitted the release of "the results of my drug and alcohol assessment" and allowed for the consent to be revoked only in writing.
Client #4 was admitted on 1/11/17 and was discharged on 6/20/17. A consent to release to a government agency, dated 12/27/16, permitted the release of "the results of my drug and alcohol assessment" and allowed for the consent to be revoked only in writing.
Client #5 was admitted on 10/10/16 and was discharged on 2/7/17. A consent to release to a government agency, dated 10/10/16, permitted the release of "the results of my drug and alcohol assessment" and allowed for the consent to be revoked only in writing.
Client #6 was admitted on 11/18/16 and was discharged on 3/29/17. A consent to release to a government agency, dated 11/11/16, permitted the release of "the results of my drug and alcohol assessment" and allowed for the consent to be revoked only in writing.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Client records #1 will have consent forms redone to adhere to Pa.Code 255.5, including removing information to government agency permitting the release of the results of the drug and alcohol assessment.
Erie staff will participate in state mandated trainings on Confidentiality at BHTEN within 6 months.
Clinical supervisor will conduct in-house trainings to educate staff on how to complete releases of information forms during staff meetings beginning 7/14/2017.
Clinical supervisor will oversee intake documentation to ensure adherence to the five areas listed in Pa.Code 255.5.
Clinical supervisor will review all participant charts weekly to ensure all intake and confidentiality forms are correctly filled out. |
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
Seven client records were reviewed on July 11, 2017. The facility failed to document a comprehensive treatment plan during intake in client records, #1, 4 & 7.
Client #1 was admitted on 1/19/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan was not documented until 3/7/17.
Client #4 was admitted on 1/11/17 and was discharged on 6/20/17. There was no comprehensive treatment plan documented in the record.
Client #7 was admitted on 12/2/16 and was discharged on 6/5/17. The comprehensive treatment plan was not documented until 3/7/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The facility clinical supervisor will be responsible for training Counselors on rehabilitation plans for all clients within intake and admission.
The training will occur on 7/14/17 during clinical staff meeting.
The clinical supervisor will review files monthly to ensure staff compliance and appropriate content. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Seven client records were reviewed on July 11, 2017. The facility failed to provide treatment according to the treatment plan in client records, #1, 2 & 7.
Client #1 was admitted on 1/19/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan, dated 3/7/17 and treatment plan updates dated 5/3/17 and 5/17/17, indicated that the facility would provide (1) individual counseling session per week, however individual counseling sessions were documented only on 3/7/17, 4/12/17, 5/3/17 and 5/18/17.
Client #2 was admitted on 1/20/17 and was an active client at the time of the licensing inspection. The comprehensive treatment plan, dated 2/20/17, and treatment plan updates dated 4/20/17 and 6/21/17, indicated that the facility would provide (1) individual counseling session per week, however individual counseling sessions were documented only on 2/15/17, 3/1/17, 3/9/17, 3/29/17, 6/6/17, 6/16/17 and 7/5/17.
Client #7 was admitted on 12/2/16 and was discharged on 6/5/17. The comprehensive treatment plan, dated 3/7/17 and a treatment plan update dated 5/6/17, indicated that the facility would provide (1) individual counseling session per week, however individual counseling sessions were documented only on 12/27/16, 3/1/17, 1/4/17, 3/7/17, 3/21/17, 4/11/17 and 5/9/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will ensure client#1 and #2 receive individual session in adherence to days and times as indicated on the treatment plan.
All clients at Erie OP will be provided treatment according to treatment plan.
Any clients missing individual sessions will receive follow up calls to reschedule sessions and documentation will be placed in clients chart stating attempts to engage clients.
Clinical supervisor and lead counselor will monitor every client service to ensure adherence to days and times for service as indicated on the treatment plan.
Documentation for services will be filed daily into charts to reflect services by counselors. |