INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Passages to Recovery, Inc., 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) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire in five of seven records.Client #1 was admitted to the outpatient level of care on October 23, 2024, and was still active at the time of inspection. A release of information form to the funding source was signed on October 23, 2024, and did not document when the consent will expire.Client #2 was admitted to the outpatient level of care on January 22, 2025, and was still active at the time of inspection. A release of information form to the funding source was signed on January 22, 2025, and did not document when the consent will expire.Client #4 was admitted to the outpatient level of care on February 3, 2025, and was still active at the time of inspection. A release of information form to the funding source was signed on February 3, 2025, and did not document when the consent will expire.Client #5 was admitted to the outpatient level of care on January 3, 2025, and discharged on February 21, 2025. A release of information form to the funding source was signed on February 12, 2025, and did not document when the consent will expire.Client #6 was admitted to the outpatient level of care on December 17, 2024, and discharged on March 10, 2025. A release of information form to the funding source was signed on December 17, 2024, and did not document when the consent will expire.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Release for funding source was updated in the EHR to read "This consent is set to expire one year after signing and I may revoke this consent to release information at any time in writing or orally, except to the extent that action has been taken in reliance of it."
Passages to Recovery hired a Director of Clinical Compliance on 06/30/2025. The director will assist Director of Clinical Services and Clinical Supervisor in regular and random audits of client charts to ensure clinical compliance including Release of Information requirements. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document case consultations in three of seven records. The facility's policy states a case consultation will be completed every 90 days.Client #1 was admitted to the outpatient level of care on October 23, 2024, and was still active at the time of inspection. A case consult was completed on February 6, 2025, and the next one was due no later than May 6, 2025; however, it was completed on May 23, 2025. Client #2 was admitted to the outpatient level of care on January 22, 2025, and was still active at the time of inspection. A case consult was completed on February 6, 2025, and the next one was due no later than May 6, 2025; however, it was completed on May 24, 2025.Client #4 was admitted to the outpatient level of care on February 3, 2025, and was still active at the time of inspection. A case consult was completed on February 12, 2025, and the next one was due no later than May 12, 2025; however, it was completed on May 24, 2025. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Outpatient staff attended a documentation training with Director of Clinical Supervisor on 07/08/2025 reviewing the timeframes and expectations of all clinical documentation, including case consults.
Passages to Recovery hired a Director of Clinical Compliance on 06/30/2025. The director will assist Director of Clinical Services and Clinical Supervisor in regular and random audits of client charts to ensure clinical compliance.
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