INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2022 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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704.11(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 all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in two of two applicable personnel records reviewed.
Employee # 3 was hired as a counselor on May 13, 2021 and was due to have the HIV/AIDS training and the TB/STD training no later than May 13, 2022. The HIV/AIDS and TB/STD trainings were not completed at the time of the inspection.
Employee # 4 was hired as a counselor on July 12, 2021 and was due to have the TB/STD training no later than July 12, 2022. The TB/STD training was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #3 and #4 will register for Basic HIV training by 9/1/2022. All new employees will register for Basic HIV training within the next 3 months.
Employee #3 will register for TB/STD training by 9/1/2022
Program Manager will monitor training files monthly to assure all mandatory trainings are completed within guidelines. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made to on consent to release information forms in three of seven client records reviewed.
Client # 1 was admitted on October 12, 2021 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client and witness on October 12, 2021; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made to.
Client # 3 was admitted on January 11, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client and witness on January 11, 2022; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made to.
Client # 7 was admitted on November 17, 2021 and was discharged on June 6, 2022. The release of information form to an emergency contact was signed and dated by the client and witness on November 17, 2021; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made to.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 8/5/2022 a training with all clinical staff will be conducted during staff meeting on proper procedure when completing release information. The name of the person, agency, or organization will be included on the emergency contact to whom the disclosure would be made to.
Client #1, 3 and 7 were corrected on 8/4/2022 to include the name of the emergency contact person on the ROI.
Ongoing training will be conducted with all new staff. Program Manager/Clinical Supervisor will audit charts after completion of intake to assure forms are completed correctly. |
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
Based on a review of client records, the facility failed to assure that counseling services were provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client # 1 was admitted on October 12, 2021 and was still active at the time of the inspection. The individual treatment and rehabilitation plan, dated November 18, 2021, indicated the client was to receive three group therapy session per week (twelve group sessions per month). The client's record of service and progress notes indicated that the client received one group session in the month of December 2021.
Client # 2 was admitted on October 25, 2021 and was still active at the time of inspection. The individual treatment and rehabilitation plan, dated November 25, 2021, indicated the client was to receive two group therapy sessions per week (eight group sessions per month). The client's record of service and progress notes indicated that the client received no group sessions in the month of December 2021.
Client # 6 was admitted on July 20, 2021 and was discharged on January 27, 2022. The individual treatment and rehabilitation plan, dated August 5, 2021, indicated the client was to receive two group therapy session per week (eight sessions per month). The client's record of service and progress notes indicated that the client received two group sessions in the month of September 2021.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff training will be held during staff meeting on 8/5/2022 assuring counseling services were provided to clients according to the treatment plan. If after outreach to remind client of their perspective services a note will be placed in the file noting outreach attempts and no show for the service scheduled.
Program Manager will audit sample charts monthly to assure correct documentation is in the charts |