INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 28, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Berks Counseling Center, 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) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent to release information forms in four of seven applicable client records reviewed.
Client #1 was admitted on November 27, 2023 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on November 27, 2023; however, the specific information to be disclosed was not included on the release form.
Client #3 was admitted on September 29, 2023 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on September 29, 2023; however, the specific information to be disclosed was not included on the release form.
Client #5 was admitted on August 7, 2023 and was active at the time of inspection. A release of information form to the funding source was signed and dated by the client on August 7, 2023; however, the specific information to be disclosed was not included on the release form.
Client #7 was admitted on August 16, 2023 and was discharged on December 19, 2023. A release of information form to the funding source was signed and dated by the client on August 16, 2023; however, the specific information to be disclosed was not included on the release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After looking into this matter, Clinic Director found that the verbiage was in the consent when the client signed; however, the settings for the form were incorrectly configured causing the language to be missing from the completed service. For previous impacted services, the verbiage is visible by going into a separate mode in the note.
Clinic Director and Project Evaluator were able to correct the settings so that all verbiage will be visible in the completed services moving forward. This is a permanent fix, no further monitoring will be required.
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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 maintain a complete client record, which is to include case consultation notes, in six of six applicable client records reviewed.
Client #2 was admitted on May 15, 2023 and was discharged on September 12, 2023. There was no documentation, in the record, of case consultation notes during the treatment episode.
Client #3 was admitted on September 29, 2023 and was active at the time of inspection. There was no documentation, in the record, of case consultation notes as of the date of the inspection.
Client #4 was admitted on August 29, 2023 and was active at the time of inspection. There was no documentation, in the record, of case consultation notes as of the date of the inspection.
Client #5 was admitted on August 7, 2023 and was active at the time of inspection. There was no documentation, in the record, of case consultation notes during the treatment episode.
Client #6 was admitted on September 29, 2023 and was discharged on January 29, 2024. There was no documentation, in the record, of case consultation notes during the treatment episode.
Client #7 was admitted on August 16, 2023 and was discharged on December 19, 2023. There was no documentation, in the client record, of case consultation notes during the treatment episode.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinic Director will update the policy by 4/30/24 to accurately reflect the process for case consultation. Department Leaders and Team Leaders will review the policy with all staff members by 5/15/24. The QA Specialist will conduct quarterly reviews for one year to ensure adherence to policy changes and submit a report to Clinic Director for follow up. |
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.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record, which is to include follow up information, in one of three applicable client records reviewed.
Client #7 was admitted August 16, 2023 and was discharged on December 19, 2023. There was no follow-up information documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Department Leaders and Team Leaders will review the follow up expectation with all staff by 4/15/24. The Medical Records Coordinator will verify that all follow up calls are completed prior to inactivating the chart. |
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
Based on a physical plant inspection, the facility failed to conspicuously display an emergency telephone number to the general public.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A temporary sign that includes a phone number for emergency situations has been placed in a conspicuous location. A permanent sign will be placed by the Office Manager by 4/30/24. |