INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from January 3-4, 2013, 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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704.7(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 upon the review of employee records, the facility failed to provide documentation that counselors met the credential and/or experiential requirements for the position in two of eight employee records.
The findings include:
Eight employee records were reviewed from December 11-12, 2012, as part of an administrative review. The facility failed to provide verification that an employee met the credential and/or experiential requirements for the position of counselor in employee records # 6 and 9.
Employee # 6 was hired as a Bachelor's level counselor on July 12, 2012. However, as of the date of inspection, the record did not include verification that employee # 6 had the required one year of experience.
Employee # 9 was hired as a Bachelor's level counselor on October 17, 2012. However, as of the date of inspection, the record did not include verification of a related degree.
The findings were confirmed during the record review by the representative from the Human Resources Department.
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Plan of Correction
Employee #6 (hired 7-12-12) will be removed from the counseling staff at 2/15/2013. An alternative placement within the company will be sought out. If no placement is available she will be terminated. All future counselors hired will meet the regulations outlined in standard 704.7(b).
Employee #9 (hired 11-17-12) employee has submitted verification of BA degree in Psychology and original transcripts via US mail dated Jan 3-2013, confirming coursework passed ending in the year 2002. Documentation submitted to Director on 1-4-13. All future counselors hired will meet the regulations outlined in standard 704.7(b).
Administration staff on site will monitor and report on new hire information with regards to qualifications for a given job position prior to an offer of employmnent.
Responsible Employee: Facility Director, Administrative Staff,
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705.26 (1) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(1) Shall have a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65F in the winter. When indoor temperatures exceed 90F, mechanical ventilation such as fans or air conditioning shall be used.
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Observations
Based upon observations of the Licensing Specialist and an interview with the Facility Director, the facility failed to maintain a heating and cooling ventilation system that is adequate to maintain an indoor temperature of at least 65 F in the winter.
The findings include:
On January 4, 2013, at approximately 10:55 AM, the Licensing Specialist heard several clients conversing about the lack of heat in the facility's group rooms. Upon inspecting Group Room B, the Licensing Specialist noticed that the room was cold and that at least 4 clients and a staff member in the room were wearing their coats and/or scarves. The Licensing Specialist then interviewed the Facility Director in regard to the heating situation. The Facility Director confirmed that on January 4, 2013, the indoor temperature on the group room side of the facility was below 65 F and that no direct heat was available.
The Facility Director confirmed that the heating issue had been ongoing for at least one week.
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Plan of Correction
The facility is in the process of negotiating a new lease in which the landlord has agreed to replace the HVAC system within one month of both parties reaching agreement which will occur by 3-01-2013. Facility Director will perform routine checks on heating system after installation and report areas of concern or malfunctions. Documentation will be kept in a log regarding the heating/cooling by the Facility Director.
Responsible Employee: Facility Director, Quality Assurance, maintenance.
The lease will be signed by 3-01-13 and within 30days of this agreement, but no later than 3-31-13, the HVAC cooling and heating system will be in full function. Treatment services have been faciliated on the heated side of building where there are no temperature problems whatsoever. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based upon a review of the facility's fire drill log, the facility failed to provide documentation of unannounced fire drills at least once a month for ten of twelve months.
The findings include:
The facility's fire drill log for the time frame of January 2012 to December 2012 was reviewed on January 3, 2013. The fire drill log did not include documentation of fire drills for the months of: January 2012, February 2012, March 2012, April 2012, May 2012, June 2012, July 2012, August 2012, September 2012 and October 2012.
The findings were confirmed by the Facility Director during the review of the fire drill log.
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Plan of Correction
Fire drills will be conducted unannounced monthly on different dates and shifts by recording days, times, number of persons involved, alternative exits. Fire Drill logs will be routinely monitored by Facility Director, Clinical Supervisor and Quality Assurance as part of standard QA reports and for regular auditing purposes to ensure that logs are being maintained with proper information as outlined in Physical Plant standards.
Responsible Employee: Facility Director, Clinical Supervisor, Quality Assurance
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based upon a review of the facility's fire drill log, the facility failed to demonstrate that it had prepared alternate exit routes to be used during fire drills for ten of twelve months.
The findings include:
The facility's fire drill log for the time frame of January 2012 to December 2012 was reviewed on January 3, 2013. The fire drill log did not include documentation of fire drills for the months of: January 2012, February 2012, March 2012, April 2012, May 2012, June 2012, July 2012, August 2012, September 2012 and October 2012. Therefore, the facility was unable to demonstrate that it had prepared and used alternate exits for the months referenced above.
The findings were confirmed by the Facility Director during the review of the fire drill log.
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Plan of Correction
Fire drills will be conducted unannounced monthly on different dates and shifts by recording days, times, number of persons involved, alternative exits. Fire Drill logs will be routinely monitored by Facility Director, Clinical Supervisor and Quality Assurance as part of standard QA reports and for regular auditing purposes to ensure that logs are being maintained with proper information as outlined in Physical Plant standards.
Responsible Employee: Facility Director, Clinical Supervisor, Quality Assurance
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based upon a review of the facility's fire drill log, the facility failed to demonstrate that it had conducted fire drills on different days of the week, at different times of the day and on different staffing shifts for ten of twelve months.
The findings include:
The facility's fire drill log for the time frame of January 2012 to December 2012 was reviewed on January 3, 2013. The fire drill log did not include documentation of fire drills for the months of: January 2012, February 2012, March 2012, April 2012, May 2012, June 2012, July 2012, August 2012, September 2012 and October 2012. Therefore, the facility was unable to demonstrate that it had conducted fire drills on different days of the week, at different times of the day and on different staffing shifts for the months referenced above.
The findings were confirmed by the Facility Director during the review of the fire drill log.
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Plan of Correction
Fire drills will be conducted unannounced monthly on different dates and shifts by recording days, times, number of persons involved, alternative exits. Fire Drill logs will be routinely monitored by Facility Director, Clinical Supervisor and Quality Assurance as part of standard QA reports and for regular auditing purposes to ensure that logs are being maintained with proper information as outlined in Physical Plant standards.
Responsible Employee: Facility Director, Clinical Supervisor, Quality Assurance
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based upon the review of Administrative Documentation, the facility failed to demonstrate that it made its annual report available to the public.
The findings include:
Administrative documentation was reviewed from December 11 - 12, 2012. The 2011 Annual Report was presented for review. However, the facility failed to present documentation that verified that the report was made available to the public.
The findings were confirmed by the current Vice President of Treatment Services.
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Plan of Correction
The annual report will be posted on the Community Education Center webite by the Director of Treatment Compliance and Program Director of Quality Assurance.The posting of the annual report will be re-verified by one or both of theses staff by the end of the referred to fiscal year to ensure it is publically available on the website. Program Director of Quality Assurance will continue to monitor this website routinely to assure that it is publically available.
Responsible Employee: Director of Treatment Compliance
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based upon the review of employee records, the facility failed to provide the results of reference investigations in three of eight records.
The findings include:
Eight employee records requiring the results of reference investigations were reviewed from December 11-12, 2012, as part of an administrative review. The facility failed to provide the results of a minimum of two reference checks in records # 3, 5 and 6.
Employee # 3 was hired on November 12, 2012. As of the date of inspection, the record did not include the results of a second reference investigation.
Employee # 5 was hired on July 2, 2012. As of the date of inspection, the record did not include the results of a second reference investigation.
Employee # 6 was hired on July 12, 2012. As of the date of inspection, the record did not include the results of any reference investigations.
The findings were confirmed during the record review by the representative from the Human Resources Department.
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Plan of Correction
It was determined that employee records were not in compliance with standard 709.26(d)(2). The following reference checks were made on the following employees:
Employee#3 a 2nd reference check was conducted and contacted on 1-23-13.
Employee#5 a second reference was contacted on 1-18-13.
Employee#6 Two reference checks were conducted and contacted on 1-23-13.
Administration staff on site will now monitor personnel records which include applications of employment to monitor and check for multiple reference checks, verification of employee rights were given via employee handbook sign-off, and other required data as outlined in personnel management regulations. When the personnel records do not reflect these requirements and this data, it will be made aware to the Facility Director immediately. The Facility Director will then review and amend the personnel record as needed.
Responsible Employee: Facility Director, Administrative Staff
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709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based upon the review of employee records, the facility failed to provide verification that employees were notified of their rights in 4 of 7 records.
The findings include:
Employees are to be notified of the following rights upon employment:
(1) The employee's right to inspect his own records.
(2) The employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
(3) The employee's right to submit rebuttal data or memoranda to his own records.
As per a human resources representative, the facility utilized a sign-off form in the employee record as verification that the employee was notified of their rights.
Seven employee records were reviewed from December 11-12, 2012. The facility failed to provide verification that employees were notified of their rights in records # 2, 5, 6 and 8.
Employee # 2 was hired on October 17, 2012. The facility was required to notify the employee of their rights no later than October 24, 2012. However, as of the date of inspection, the record did not include the employee rights sign-off form.
Employee # 5 was hired on July 2, 2012. The facility was required to notify the employee of their rights no later than July 9, 2012. However, as of the date of inspection, the record did not include the employee rights sign-off form.
Employee # 6 was hired on July 12, 2012. The facility was required to notify the employee of their rights no later than July 19, 2012. However, as of the date of inspection, the record did not include the employee rights sign-off form.
Employee # 8 was hired on July 19, 2012. The facility was required to notify the employee of their rights no later than July 24, 2012. However, as of the date of inspection, the record did not include the employee rights sign-off form.
The findings were confirmed during the record review by the representative from the Human Resources Department.
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Plan of Correction
It was determined that employee records were not in compliance with standard 709.26(d)(2). The following employees did not have verification that they were made aware of their employee rights:
Employee#2 Employees rights are in the handbook, including a signature page indicating receipt of this handbook and the subsequent policy which can be found on page 32-33 of the employee handbook, and the policy is referenced on page 33. The second paragraph of Employee Access to records discusses materials which an employee may disagree with and how to handle information.
Employee#5 Employees rights are in the Handbook including a signature page indicating receipt of this handbook and the subsequent policy which can be found on page 32-33 of the employee handbook, and the policy is referenced on page 33. The second paragraph of Employee Access to records discusses materials which an employee may disagree with and how to handle information.
Employee#6 Employees rights are in the handbook, including a signature page indicating receipt of this handbook and the subsequent policy which can be found on page 32-33 of the employee handbook, and the policy is referenced on page 33. The second paragraph of Employee Access to records discusses materials which an employee may disagree with and how to handle information.
Employee# 8 Employees rights are in the handbook, including a signature page indicating receipt of this handbook and the subsequent policy which can be found on page 32-33 of the employee handbook, and the policy is referenced on page 33. The second paragraph of Employee Access to records discusses materials which an employee may disagree with and how to handle information.
Administration staff on site will now monitor personnel records upon hire or within the first 7 days of employment to monitor and check for multiple reference checks, verification of employee rights were given via employee handbook sign-off, and other required data as outlined in personnel management regulations. When the personnel records are reviewed by the administrative assistant and do not reflect these requirements and this data, it will be made aware to the Facility Director, in writing, to be rectified within a 7 day time frame from notification of this necessary criteria. At that point, The Facility Director will then review and amend the personnel record as needed.
Responsible Employee: Facility Director, Administrative Staff
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709.93(a)(2) 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:
(2) Medication records.
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Observations
Based upon the review of client records, the facility failed to document medication records to include the name of the drug, dosage and/or frequency of use in four of eleven records.
The findings include:
Eleven client records were reviewed from January 3-4, 2013. The facility failed to document medication records to include the name of the drug, dosage and/or frequency of use in client records # 3, 4, 7 and 9.
Client # 3 was admitted on August 28, 2012, and was still an active client on the date of inspection. The record included documentation that the client was taking a prescription medication. However, the facility failed to document the drug's name, dosage and frequency of use.
Client # 4 was admitted on October 3, 2012, and was still an active client on the date of inspection. The record included documentation of five drugs that the client was taking. However, the facility failed to document the dosage and frequency of use for all five drugs.
Client # 7 was admitted on September 13, 2012, and was still an active client on the date of inspection. The record included documentation of seven drugs that the client was taking. However, the facility failed to document the dosage for six of the drugs and the frequency of use for all seven drugs.
Client # 9 was admitted on August 14, 2012, and was discharged on October 30, 2012. The record included documentation of seven drugs and their dosage. However, the facility failed to document the frequency of use for all seven drugs.
The findings were reviewed with the Facility Director during the record review.
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Plan of Correction
Electronic Clinical Chart will be altered to show frequency of drug use as opposed to "duration". Clinical staff will be trained on new Electronic Clinical Chart measures no later than 3/1/2013. Quality Assurance, Clinical Supervisor and Facility Director will provide continuous supervision and monitoring of clinical records to ensure medication section is completed within standards.For charts #3,4,7 and #9 corrective adjustments have been made.
This has been electronically implemented as of 2-1-13 via the electronic chart function.
Responsible Employee: Facility Director, Clinical Supervisor, Quality Assurance
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