This report is a result of an on-site licensure renewal inspection conducted on January 30, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care Center, 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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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 of seven records.
Client #2 was admitted on May 14, 2024, and discharged on October 31, 2024. A letter was faxed to a government agency on October 31, 2024. There was no consent to release information form for the government agency in client #2 ' s record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that all staff are retrained on the importance of and process for obtaining informed and voluntary consents and utilizing the appropriate documentation in the electronic health record to document any release of private health information no later than March 3, 2025 as evidenced by group supervision note(s). Staff retraining will include a focus on how to properly ensure that all necessary consents are discussed and offered to clients during the assessment process. In the electronic health record, staff will use appropriate services to document that they have obtained a valid consent to release relevant information pertaining to the client's treatment. Staff will be responsible for completing a specific service regarding any private health information disclosures which will be entered in the electronic health record to document any disclosures that are made. Chart audits will be utilized to ensure that information is only being shared with individuals/agencies in which there is a documented informed and voluntary consent in the client's electronic health record. A mock audit will occur in approximately 6 months. This audit will be conducted by another member of the Management Team and will be used to further confirm that information is only shared with the presence of a valid consent. |