INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 10, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pathway to Recovery Counseling and Educational Services 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
|
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.
|
Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed.
Client #5 was admitted on March 8, 2023 and discharged on May 26, 2023. There was a letter documented in the file that was sent to a legal department on May 26, 2023; however, the facility did not have documentation that a release of information form was signed by the client.
This is a repeat citation from the December 20, 2022 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
During Treatment Team Meeting held on January 19, 2024 the Clinical Director educated all counselors regarding the importance of completing a consent prior to sending any documentation for the purpose of care coordination. The Clinical Director will conduct internal chart reviews throughout the year to ensure compliance is maintained. The agency will be in full compliance with this standard effective 01/19/2024. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in four out of four discharged records reviewed.
Client #4 was admitted on January 4, 2023 and discharged on April 6, 2023.
Client #5 was admitted on March 8, 2023 and discharged on May 26, 2023.
Client # 6 was admitted on March 22, 2023 and discharged on June 28, 2023.
Client #7 was admitted on April 3, 2023 and discharged on July 5, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
During a meeting held on January 19, 2024 the issue of client follow-up was discussed with the counseling staff and the receptionists. The following procedure has been put in place: upon completing the discharge of a client, the counselor will submit a letter template with the client's name, address, and discharge date to the receptionist within 7 days. The client will then be placed on a list that will be monitored by the Clinical Director on a weekly basis until the follow-up letters are completed and sent within a 30-day period to the client. The Clinical Director will conduct internal chart reviews throughout the year to ensure compliance is maintained. The agency will be in full compliance with this standard effective 01/19/2024. |