INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 27, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Impact Counseling Services, 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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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated signature of the client in one of seven records.
Client #7 was admitted on April 12, 2023 and discharged on July 19, 2023. An informed and voluntary consent to disclose information to a mobile crisis unit was signed by the guardian on July 12, 2023, rather than the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be educated on obtaining client signatures on all releases of information. Chart audits will be done monthly by project and facility directors to ensure compliance. |