INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on April 7 - 8, 2010 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 and a plan of correction is due on May 5, 2010.
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document a written individual training plan for the project director.
The findings include:
Seven personnel records were reviewed on April 7, 2010. Five records required documentation of an individual training plan. The facility did not document an individual training plan in personnel record #1.
An interview with the facility director was conducted on April 8, 2010. The facility director confirmed that an individual training plan had not been documented in personnel record #1.
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Plan of Correction
Training plan covers the employee from the 91st day of employment through December 31st of the current calendar year. Subsequent Training Plans will cover 1/1 through 12/31 of each year thereafter. MinSec Treatment LLC will comply with the requirements of the Bureau of Drug and Alcohol programs to ensure that all employees receive at least the minimum required number of training hours annually.
The Project Director will submit an analysis of perceived training needs to the Chief Operating Officer. The Chief Operating Officer will review and approve the needs using the internal training plan form. The Project Director will submit this information by January 1 of each subsequent year.
All training plans will be available at the time of Department of Health audit.
Responsible Employee:
Program Director
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on the review of administrative documentation and an interview with the facility director, the facility failed to document an independent annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative documentation was reviewed and an interview with the project director was conducted on April 7, 2010. The facility was required to document an annual audit of financial activities. The facility did not document a financial audit for the years 2008/2009 fiscal year.
The facility director confirmed that a financial audit had not been completed.
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Plan of Correction
The Chief Financial Officer will obtain an annual audit for fiscal year of financial activities associated with the project's drug and alcohol services. This audit will be facilitated by an independent public accountant. The Chief Operating Officer will monitor the auditing process with the accountants and ensure that an annual audit be available for at time of Department of Health audit.
Responsible Employee:
Chief Financial Officer
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a tour of the facility's physical plant and based on an interview with the clinical supervisor, the facility failed to maintain the confidentiality of the client's identity.
The findings include:
A tour of the facility's physical plant and an interview with the clinical supervisor on April 8, 2010 at approximately 11:15 A.M. The licensing specialist observed a client sign-in book at the reception desk, with the first and last names of a client presently or previously at the facility.
The clinical supervisor confirmed their practice of having all clients sign the sign-in book upon arrival.
The licensing specialist observed client files in containers in a public area not secure within locked storage containers.
The clinical supervisor confirmed their practice of having all clients selecting their own file to record their signature on the record of service sheet.
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Plan of Correction
The client confidentiality will be further enhanced by the Client Record of Service sheets being kept in a secured file cabinet at the front desk. Clients will come to the front desk one at a time to request their folder from staff. The folder will be returned to the file cabinet at the conclusion of treatment services. The treatment service will be signed by the clinician who provided the treatment service.
The client will sign the book at the front desk using their first name and their last name initial
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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 the review of client records and a review of the policy and procedures, the facility failed to document follow-up information within thirty days from the date of discharge in one of one client records.
The finding include:
Eight client records were reviewed on April 8, 2010. One client record required documentation of follow-up information. The facility did not document follow-up information within thirty days from the date of discharge, as per facility policy, in client record #8.
The facility's policy titled "Follow Up Procedure" states:
POLICY
The Minsec Treatment, LLC will perform short-term follow-up designed to ensure continuity of care, effectiveness of our referral mechanisms and to encourage further use of resources by the individual who have completed the program.
The follow-up process also provides a valuable resource that provides clients with the resources to move along a continuum of care that consistently meets individual needs and provides uninterrupted services.
PROCEDURE (POST DISCHARGE)
1. With client's written consent and within 30 days the primary counselor or the continuing care specialist will call the telephone number of the client.
2. If no phone number is available, a letter will be sent to the client at the last known address to check the client's post-treatment progress and encourage the client to contact Minsec if he/she needs further assistance.
All post-treatment contacts or attempts to contact will be logged in a follow-up book for facility records.
Client #8 was admitted to the program on 5/1/09 and discharged on 6/3/09, follow-up was documented late on 9/3/09.
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Plan of Correction
Client follow up will be made on bi-weekly basis. A call will be placed to clients discharged within the prior two weeks. If the client is inaccessible via phone a letter will be mailed to the client's last known address.
Responsible Employee:
Clinical Assistant
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