INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on February 22, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in two of seven client records reviewed.Client # 1 was admitted on September 21, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.Client # 2 was admitted on July 14, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the pandemic clients will be permitted in the building after a wellness check to sign consents and intake paperwork. A telephone call will be made to all active clients between 3/15/21- 4/15/21 to come into the facility to sign all consents . Once clients are permitted on-site they will sign all consents at time of intake. Clinical Supervisor will review all intake paperwork for accuracy. |
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 client records, the facility failed to document the dated signature of the client on release of information forms in two of seven client records reviewed. Client # 1 was admitted on September 21, 2020 and was still active at the time of the inspection. The release of information forms to a government agency, a transportation company, a laboratory, a funding source and an emergency contact were signed and dated by the witness on September 21, 2021, but all of the release forms were not signed by the client. Client # 2 was admitted on July 14, 2020 and was still active at the time of the inspection. The release of information forms to a government agency, a parole officer, a transportation company, a laboratory, a funding source and an emergency contact were signed and dated by the witness on July 13, 2020, but all of the release forms were not signed by the client. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During the pandemic clients will be permitted in the building after a wellness check to sign consents and intake paperwork. A telephone call will be made to all active clients between 3/15/21- 4/15/21 to come into the facility to sign all consents . Once clients are permitted on-site they will sign all consents at time of intake. Clinical Supervisor will review all intake paperwork for accuracy. |
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 client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in four of four applicable client records reviewed. Client # 1 was admitted on September 21, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was completed on October 15, 2020 and an update was due no later than December 15, 2020; however, the update was not completed until January 7, 2021. Client # 2 was admitted on July 14, 2020 and was still active at the time of the inspection. A treatment plan update was completed on October 13, 2020 and the next update was due no later than December 13, 2020; however, there was no update completed at the time of the inspection. Client # 3 was admitted on December 23, 2019 and was still active at the time of the inspection. A treatment plan update was completed on November 3, 2020 and the next update was due no later than January 3, 2021; however, there was no update completed at the time of the inspection. Client # 5 was admitted on September 5, 2019 and was discharged on January 24, 2020. A treatment plan update was completed on October 24, 2019 and the next update was due no later than December 24, 2019; however, there was no update completed prior to discharge. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director and Clinical Supervisor conducted training with all clinical staff during staff meeting on 3/5/2021 on documentation time frames and requirements including but not limited to treatment plan updates. Client #2 and Client #3 treatment plan updates will be updated by 3/30/21. Chart reviews will be conducted weekly as a quality assurance measure to assure treatment plans are updated in a timely manner. |
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 document follow up information in the client record in two of two applicable client records reviewed. Client # 6 was admitted on October 10, 2019 and was discharged on January 16, 2020. The client record failed to document follow up information regarding the client as of the date of the inspection. Client # 7 was admitted on August 16, 2019 and was discharged on December 24, 2019. The client record failed to document follow up information regarding the client as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility director and Clinical Supervisor will conduct training with all clinical staff during staff meeting and during individual supervision on documentation requirements including but not limited to follow up letters upon discharge. Clinical Supervisor will conduct chart reviews weekly as a quality assurance measure to assure follow-up documentation is included in the charts |