D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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MINSEC TREATMENT LLC
3768 L STREET
PHILADELPHIA, PA 19124

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Survey conducted on 01/19/2012

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on January 18 through 19, 2012 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:	Plan of Correction
705.26 (2) LICENSURE Heating and cooling. 705.26. Heating and cooling. The nonresidential facility: (2) May not permit in the facility heaters that are not permanently mounted or installed.
Observations Based on the physical plant inspection, the facility failed to ensure that there were no heaters within the facility that were not permanently mounted or installed. The findings include: The physical plant inspection was conducted on January 19, 2012, with the Facility Director (FD) present. During the inspection, four moveable space heaters were found in a storage closet that was located toward the rear of the facility. The FD confirmed that the heaters were used on particularly cold days during the 2010-2011 winter. The findings were re-confirmed by the FD during the exit interview.	Plan of Correction The four moveable space heaters were removed from the building on 1/19/12. The facility will not permanently mount any space heaters at any time. The facility is in the process of having the HVAC system repaired by the landlord on 3/5/12. The Facility Director will be responsible for ensuring that there are no space heaters in the building at any given time and will conduct at weekly inspection of the counselors offices beginning 1/23/12.
709.22(c)(2) LICENSURE Governing Body 709.22. Governing body. (c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to: (2) Qualifications for membership.
Observations Based on a review of the project's Policy & Procedures Manual, the Governing Body By-Laws and corporate Voting Agreement, the project failed to adopt a policy that outlines the qualifications for membership on the Board of Directors. The findings include: The project's Policy & Procedures Manual, the Governing Body By-Laws and corporate Voting Agreement were reviewed from January 4 - 6, 2012. The Licensing Specialist was unable to locate a policy that outlined the qualifications for membership on the Board of Directors. The findings were confirmed during the exit interview with the project's Executive Medical Officer and Regional Director of Treatment Services.	Plan of Correction Minsec's Board Of Directors will create and adopt a policy regarding qualifications for Board members per policy 709.22 (C). These qualifications will be added as an amendment to the governing body by-laws. Qualifications will be reviewed annually by the board and updated if necessary.
709.22(c)(3) LICENSURE Governing Body 709.22. Governing body. (c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to: (3) Criteria for continued membership.
Observations Based on a review of the project's Policy & Procedures Manual, the Governing Body By-Laws and corporate Voting Agreement, the project failed to adopt a policy that outlines the criteria for continued membership on the Board of Directors. The findings include: The project's Policy & Procedures Manual, the Governing Body By-Laws and corporate Voting Agreement were reviewed from January 4 - 6, 2012. The Licensing Specialist was unable to locate a policy that outlined the criteria for continued membership on the Board of Directors. The findings were confirmed during the exit interview with the project's Executive Medical Officer and Regional Director of Treatment Services.	Plan of Correction Minsec's Board of Directors will create and adopt a policy outlining criteria for continued membership per 709.22 (C). The continued membership criteria will be added as an amendment to the governing body by-laws. Criteria will be reviewed by the Board annually and updated if necessary.
709.22(d)(1) LICENSURE Governing Body 709.22. Governing body. (d) The duties of the governing body include, but are not limited to, the following: (1) Selecting a project director as the person officially responsible to the governing body.
Observations Based upon a review of the Project's Organizational Chart, the governing body failed to select a Project Director (PD) as the person officially responsible to the governing body. The findings include: The Project's Organizational Chart was reviewed on January 5, 2012. The chart lists the Chief Executive Officer (CEO) at the top of the chart, just below the Board of Directors. The chart then lists the PD right under the CEO. Therefore, while the PD was directly responsible to the CEO they were not the person who was officially responsible to the Board of Directors. The CEO was directly responsible to the Board of Directors. The findings were confirmed during dialogue with the PD, the Regional Director of Treatment Services and the Executive Medical Officer.	Plan of Correction Minsec ' s Governing Body will identify an appropriate staff member to serve as project director per policy 709.22 (D) and licensing alert 05-05. The project director will meet 28 PA Code 704.5 (C) of the staffing requirements for drug and alcohol treatment activities as well as the training requirements of 28 PA Code 704.11 (B), (C), (D) (1) and (D) (2).
709.28(c) 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 shall be in writing and include, but not be limited to:
Observations Based upon the review of client records, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in the client record. The findings include: Six client records were reviewed for consent forms and disclosures of information on January 19, 2012. In 1 of 6 records reviewed, specifically record # 2, the facility failed to obtain signed consent forms from the client for the release of information that had been released. Client # 2 was admitted on November 21, 2011, and was still an active client at the time of the survey. Record # 2 contained two disclosures	Plan of Correction Upon intake/admission the counselor will obtain all informed and voluntary consents for disclosure of information contained in the client record. The Facility Director/Clinical Supervisor will review the clinical record to ensure that all informed and voluntary consents for disclosure of information are obtained at time of admission. The Facility Director/Clinical Supervisor will review the clinical record on a monthly basis to ensure that all neccessary informed and voluntary consents for information are obtained prior to the dislcsoure of information.
709.93(a)(5) 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: (5) Progress notes.
Observations Based upon a review of client records, specifically progress notes and records of service, the facility failed to include individual and group progress notes for sessions reflected on the records of service. The findings include: Six client records requiring a record of service and documentation of progress notes were reviewed on January 18, 2012. Five of six records reviewed, specifically record #'s 1, 3, 4, 5 and 6, failed to include individual and / or group progress notes that were recorded on the record of service. Client # 1 was admitted on July 26, 2011, and was still an active client at the time of the inspection. Record # 1 failed to include documentation of the following individual and group sessions that were reflected on the record of service: Individual - August 26, 2011; September 16, 23, 30, 2011; October 7, 2011; November 21, 2011 Group - August 3, 5, 12, 19, 2011; September 23, 2011; October 21, 2011; November 2, 4, 11, 18, 23, 30, 2011; December 7, 9, 14, 21, 23, 28, 30, 2011 Client # 3 was admitted on September 6, 2011, and was still an active client at the time of the inspection. Record # 3 failed to include documentation of the following individual and group progress notes that were reflected on the record of service: Individual - September 16, 23, 2011; October 14, 21, 28, 2011; November 4, 21, 2011 Group - September 15, 22, 23, 2011; October 20, 21, 25, 26, 28, 2011; November 4, 11, 2011; December 9, 23, 30, 2011 Client # 4 was admitted on November 2, 2011, and was still an active client at the time of the inspection. Record # 4 failed to include documentation of the following individual and group progress notes that were reflected on the record of service: Individual - November 2, 30, 2011; December 28, 2011 Group - December 14, 2011 Client # 5 was admitted on June 2, 2011, and was discharged on November 23, 2011. Record # 5 failed to include documentation of the following individual and group progress notes that were reflected on the record of service: Individual - July 5, 12, 14, 26, 2011; August 9, 16, 23, 30, 2011; September 6, 13, 20, 2011; October 5, 11, 18, 25, 2011; November 1, 8, 15, 22, 2011 Group - June 2, 6, 13, 20, 27, 2011; July 27, 2011; August 3, 24, 31, 2011; September 7, 14, 21, 28, 2011; October 6, 12, 19, 26, 2011; November 9, 23, 2011 Client # 6 was admitted on March 24, 2011, and was discharged on September 7, 2011. Record # 6 failed to include documentation of the following individual and group progress notes that were reflected on the record of service: Individual - June 1, 25, 2011 Group - March 28, 31, 2011; April 5, 6, 14, 18, 25, 27, 28, 2011; May 4, 11, 16, 18, 19, 23, 25, 26, 31, 2011; June 3, 6, 8, 10, 13, 14, 22, 23, 25, 27, 28, 2011; July 6, 7, 11, 12, 13, 20, 21, 25, 27, 2011; August 3, 10, 16, ,19, 23, 24, 30, 31, 2011; September 6, 7, 2011	Plan of Correction The Facility Director/Clinical Supervisor will conduct a staff meeting with staff members to ensure that the understanding of the documentation of all records are placed in the chart in a timely fashion. The counselors will be provided with a reasonable time frame to ensure all documentation is completed and filed. In addtion to the policy and procedure manual will reflect the efficacy and timeline for the documentation to be in every clinical record. The Facility Director/Clinical Supervisor will require that all individual progress notes be filed in the clinical record at the close of business each day and the group notes be filed by the end of each week and The Facility Director/Clinical Supervisor will be responsible for monitoring this by randomly reviewing the charts on a monthly basis. The Facility Director/Clinical Supervisor has had the counselors file the notes that were not in the clinical record at the time of the inspection. The Facility Director/Clinical supervisor worked with all current counselors to ensure that all notes were filed in the cited clinical record as of 1/23/12.