INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26th, 2019 of MinSec Treatment LLC by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The project director failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following component: A mechanism to collect feedback on completed training.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will create a training evaluation to be completed by each staff member within 48 hours of completing training. The training evaluation will be uploaded into the Facility Learning Management System for each employee by the Human Resource Specialist |
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 and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #3 and #7 received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.Employee #3 was hired as the clinical supervisor on January 16, 2018 and was due to have the communicable disease trainings no later than January 16, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee #7 was hired as a counselor on January 22, 2018 and was due to have the communicable disease trainings no later than January 22, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training until February 4, 2019 and the TB/STD training until January 29th, 2019.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will complete the communicable diseases and HIV training by 10/30/2019. These trainings will be set up by the Human Resource Specialist. Certificates will be placed in Clinical Supervisor's file.
Human Resource Specialist will be responsible for setting up any mandatory trainings for all new employees within the allotted time frame. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document what exit was used during three out of eleven fire drills conducted in 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All current employees will be trained during staff meetings on proper protocol for completing fire drills and the corresponding documentation. Fire drill training will be added to the on the job training curriculum for all new employees. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client rights, the facility failed to include: A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will add to the client rights form and review with the clinical staff during staff meeting A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's written policies and procedures on client rights the facility failed to include that the project may not discriminate in the provision of services on the basis of marital status.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will add to the facility's written policy and procedures on client rights that the project may not discriminate in the provision of services on the basis of marital status.
This policy will be reviewed by Area Manager for approval and reviewed with the clinical staff during staff meeting. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of facility policy and procedures, the facility failed to have and implement a written policy and procedure regarding all medications used by clients which shall include, but not be limited to the administration of medication. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will create and implement a written policy and procedure regarding all medications used by clients which shall include, but not be limited to the administration of medication. The policy will be forwarded to the Area Manager for approval and reviewed with staff during staff meeting. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of seven client records, the project failed to notify the client in writing, of a decision to involuntarily terminate the client ' s treatment in three applicable records reviewed.Client #5 was admitted on September 5, 2018 and was administratively discharged on January 2, 2019.Client #6 was admitted on September 21, 2018 and was administratively discharged on March 24, 2019. Client #7 was admitted on July 27, 2018 and was administratively discharged on February 25, 2019The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will conduct a series of training on documentation to include but not limited to the notification to the client in writing, of a decision to involuntarily terminate the client's treatment. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the project's policy and procedure manual, the project did not develop and implement policies and procedures to respond to the unusual incidents for death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will develop and implement policies and procedures to respond to the unusual incidents for death or serious injury due to trauma, suicide, medication error or unusual circumstances while in treatment or, when known by facility, for ambulatory service. The policy will be reviewed and approved by Area Manager. The policy and procedure will be reviewed with the staff during staff meeting. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the project's policy and procedure manual, the project did not develop and implement policies and procedures to respond to the unusual incidents of theft, burglary, break-in or similar incident at the facility. These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will develop and implement policies and procedures to respond to the unusual incidents of theft, burglary, break-in or similar incident at the facility. The policy will be sent to Area Manager for review and approval. Policy will be reviewed with staff during staff meeting. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the project's policy and procedure manual, the project did not develop and implement policies and procedures to respond to the unusual incidents related to an event at the facility requiring the presence of police, fire or ambulance personnel. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will develop and implement policies and procedures to respond to the unusual incidents related to an event at the facility requiring the presence of police, fire or ambulance personnel. Facility Director will submit policy to Area Manager for review and approval. Policy will be reviewed with staff during staff meeting. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the project's policy and procedure manual, the project did not develop and implement policies and procedures to respond to the unusual incidents related to fire or structural damage to the facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will develop and implement policies and procedures to respond to the unusual incidents related to fire or structural damage to the facility. Policy will be submitted to Area Manager for review and approval. Policy will be reviewed with staff during staff meeting |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the project's policy and procedure manual, the project did not develop and implement policies and procedures to respond to the unusual incident of an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will develop and implement policies and procedures to respond to the unusual incident of an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. Policy will be submitted to Area Manager for review and approval. Policy will be reviewed with staff during staff meeting. |
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 seven client records, the facility failed to document treatment plan updates at least every 60 days in four client records reviewed.Client #1 was admitted on July 11, 2018 and was still active at the time of the inspection. A treatment plan update was completed on December 4, 2018 and the next update was due no later than February 4, 2019; however, there was no update documented in the record until March 19, 2019.Client #4 was admitted on January 10, 2019 and was still active at the time of the inspection. A treatment plan update was completed on February 11, 2019 and the next update was due no later than April 11, 2019; however, there was no update documented in the record until June 7, 2019. Client #5 was admitted on September 5, 2018 and was discharged on January 2, 2019. A treatment plan update was completed on September 5, 2018 and the next update was due no later than November 5, 2018; however, there was no update documented in the record at the time of the inspection.Client #6 was admitted on September 21, 2018 and was discharged on March 24, 2019. A treatment plan update was completed on December 17, 2018 and the next update was due no later than February 17, 2018; however, there was no update documented in the record at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will establish a series of training on documentation with the clinical staff. These trainings will include but not be limited to treatment planning. These trainings will take place during staff meetings. |
709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a record of service, case consultations and follow up information in client records # 5, 6 and 7. Client #5 was admitted on September 5, 2018 and was discharged on January 2, 2019. The client record did not contain documentation of case consultation notes and follow-up information.Client #6 was admitted on September 21, 2018 and was discharged on March 24, 2019. The client record did not contain documentation of case consultation notes, a complete record of service and follow-up information.Client #7 was admitted on July 27, 2018 and was discharged on February 25th, 2019. The client record did not contain documentation follow-up information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will conduct trainings during staff meetings on proper documentation in client records. Clinical Supervisor will audit client charts on a monthly basis to assure documentation is complete in clients files. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
The facility failed to display conspicuously a telephone number to the general public for emergency purpose other than "911".The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility Director replaced old sign with a new sign to display conspicuously a telephone number to the general public for emergency purpose other than 911. |