INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28, 2024 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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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 on a consent to release information form in one of seven client records reviewed. Client # 2 was admitted on September 15, 2023 and was still active at the time of the inspection. The release of information form to an emergency contact was signed by the client on September 15, 2023; however, the form did not include the name of the person, agency, or organization to whom the disclosure would be made. This is a repeat citation from the July 26, 2022 and the July 6, 2023 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program manager held a meeting with all staff in regards to repeat citations. Process of completing intake was discussed at the meeting. Name of emergency contact was added to missing form.
There will be a peer review of charts immediately following the intake process. Peer will sign off that all forms are completed. Program Manager will review charts on a weekly basis. Specific attention will be given to completion of ROI's.
Program Manager will coach staff as needed who may be in violation of this POC.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of seven client records reviewed. Client # 1 was admitted on December 6, 2023 and was still active at the time of the inspection. The release of information forms to a parole officer and an emergency contact were signed by the client December 6, 2023; however, both forms did not include the specific information to be disclosed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program manager held a meeting with all staff in regards to repeat citations. Process of completing intake was discussed at the meeting. Name of parole officer and emergency contact was added to missing form.
There will be a peer review of charts immediately following the intake process. Peer will sign off that all forms are completed. Program Manager will review charts on a weekly basis. Specific attention will be given to completion of ROI's.
Program Manager will coach staff as needed who may be in violation of this POC.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of administrative documents, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for failing to document the name of the person, agency, or organization to whom the disclosure is made on consent to release information forms was submitted and approved by the Department for the July 26, 2022 and the July 6, 2023 annual licensing inspections. Failing to document the name of the person, agency, or organization to whom the disclosure is made on consent to release information forms was again found to be a deficiency in the May 28, 2024 licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program manager held a meeting with all staff in regards to repeat citations. Process of completing intake was discussed at the meeting. Name of emergency contact and parole officers was added to missing forms.
There will be a peer review of charts immediately following the intake process. Peer will sign off that all forms are completed. Program Manager will review charts on a weekly basis. Specific attention will be given to completion of ROI's.
Program Manager will coach staff as needed who may be in violation of this POC.
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