INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6, 2023 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 at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of three applicable personnel records reviewed.
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 is a repeat citation from the July 26, 2022 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #4 is scheduled to take training in August 2023. All new employees will be given a schedule with required trainings by HR representative. This schedule will include but not be limited to 4 hours of TB/STD. Program manager will follow up on training requirements quarterly. |
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 one of seven client records reviewed.
Client # 2 was admitted on January 3, 2023 and was still active at the time of the inspection. The release of information forms to an emergency contact and parole officer were signed and dated by the client on January 3, 2023; however, the forms 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 annual licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Emergency Contact and Parole Officer names were added to the ROI for client #2. Program Manager will conduct ongoing training/coaching to all tenured and new staff on completion of all forms including but not limited to emergency contact and parole officer names included on the release of information. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan, which is to be developed with the client, in four of seven client records reviewed.
Client # 2 was admitted on January 3, 2023 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on February 3, 2023; however, there was no documentation that it was developed with the client.
Client # 4 was admitted on September 7, 2022 and was discharged on November 7, 2022. The individual treatment and rehabilitation plan was completed on October 6, 2022; however, there was no documentation that it was developed with the client.
Client # 6 was admitted on September 13, 2022 and was discharged on January 5, 2023. The individual treatment and rehabilitation plan was completed on October 13, 2022; however, there was no documentation that it was developed with the client.
Client # 7 was admitted on January 25, 2023 and was discharged on March 13, 2023. The individual treatment and rehabilitation plan was completed on February 15, 2023; however, there was no documentation that it was developed with the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program manager will train/coach clinical staff on the completion of treatment plans to include the client's signature and the completion of the treatment plan to be included in a progress note upon completion of the session. Program manager will audit charts on a monthly basis to assure all documentation is completed with client signatures |