INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pathway 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) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information contained in the client record in one of seven client records reviewed.
Client # 5 was admitted on September 3, 2025 and was discharged on December 2, 2025. There was documentation indicating contact was made with an attorney during the treatment episode; however, there was no consent to release information form signed by the client in the record prior to any of the disclosures made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that an informed and voluntary consent to release information form has been completed, signed and dated by the client prior to any disclosure of client information being made. The corrective action was implemented on March 27, 2026, after the inspection findings were reviewed during the licensing inspection process. The project director met with the lead counselor, counselors and staff to discuss and correct this issue to prevent it from happening in the future. The project director, lead counselor and all other counselors and staff will review all charts prior to to disclosing any information to ensure that the informed and voluntary consent to release information forms are signed and dated by the client. Client #5 is no longer active. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of seven client records reviewed.
Client # 2 was admitted on January 14, 2026 and was active at the time of inspection. A release of information form to an attorney was signed and dated by the client on January 14, 2026; however, there was no documentation of the purpose of the disclosure on the consent form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will ensure that on the informed and voluntary consent to release information form that the purpose of disclosure is always documented. On March 27, 2026, the project director met with the lead counselor, counselors and staff to discuss and correct this issue to prevent it from happening in the future. The project director, lead counselor and all other counselors and staff will review all consent to release information forms to ensure that the purpose of disclosure is always clearly documented on the form. The corrective action was completed on March 31, 2026 and the consent to release information form was corrected on March 31,2026. |