INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Brighter Visions Counseling 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) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency or organization to whom the disclosure is being made.Client # 7 was admitted on April 22, 2022 and was discharged June 2, 2022. An informed and voluntary consent from the client for the disclosure of information dated April 22, 2022 for the purpose of funding did not provide the name of the person, agency or organization to whom the disclosure is being made.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is policy for Brighter Visions Counseling to obtain from each client an informed and voluntary consent for the disclosure of information. This is in writing and shall include but not be limited to: (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). The consent for release of information must include the person or entity to whom it will be released, the purpose and scope of the release, and the date range during which the release is in effect. The Facility Director is responsible for the fulfillment of this policy and for this POC. Correction is made as of November 17, 2022. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client.Client # 5 was admitted on September 12, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information an emergency contact did not have the dated signature of the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is policy for Brighter Visions Counseling to obtain from each client an informed and voluntary consent for the disclosure of information. This is in writing and include but not be limited to: (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). Before treatment commences, all patients will sign and date informed consent documents attesting to their understanding of all pertinent information. The Facility Director is responsible for the fulfillment of this policy. Correction is made as of November 17, 2022. |