INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17, 2014 by staff from the Division of Drug and Alcohol 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) 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 shall be in writing and include, but not be limited to:
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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 in six of eight client records reviewed. In addition, the facility failed to obtain an informed and voluntary consent which identified the specific information to be disclosed and the purpose of disclosure in two of eight client records reviewed. The findings include:Eight client records were reviewed on December 17, 2014. All eight client records were required to include an informed and voluntary consent from the client prior to the disclosure of information. An informed and voluntary consent to release information was not obtained in record #1, 2, 4, 6, 7, and 8. An informed and voluntary consent which identified the specific information to be disclosed and the purpose of disclosure was not obtained in record #3 and 5. Client #1 was admitted on February 25, 2014 and discharged on April 10, 2014. The facility failed to obtain an informed consent signed by the client for the funding source. Client #2 was admitted on November 10, 2014 and was still an active client at the time of the inspection. The facility failed to obtain an informed consent signed by the client for the funding source.Client #3 was admitted on July 23, 2014 and was still an active client at the time of the inspection. The informed consent for the funding source was signed by the client but did not identified the specific information to be disclosed and the purpose of the disclosure.Client #4 was admitted on January 17, 2014 and was still an active client at the time of the inspection. The facility failed to obtained an informed consent signed by the client for the funding source. Client #5 was admitted on January 15, 2014 and was still an active client at the time of the inspection. The informed consent for the funding source was signed by the client but did not identified the specific information to be disclosed and the purpose of disclosure. Client #6 was admitted on January 17, 2014 and discharged on May 19, 2014. The facility failed to obtain an informed consent signed by the client for the funding source.Client #7 was admitted on November 5, 2014 and was still an active client at the time of the inspection. The facility failed to obtain an informed consent signed by the client for the funding source.Client #8 was admitted on January 20, 2014 and was still an active client at the time of the inspection. The facility failed to obtain an informed consent signed by the client for the funding source.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
This facility will be in compliance with this standard immediately. Identified client charts will be corrected at the next clinical session. An informed and voluntary consent form will be presented to each individual client at admission, and as per consent, this will become part of the client record. The standard Drug & Alcohol Release form which stipulates information to be released and the purpose of said release will be utilized for funding sources beginning immediately. This POC will be completed by the Project Director. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to verified that the client was offered a copy of the consent in five of eight records reviewed.The findings include:Eight client records requiring documentation that the client was offered a copy of the consent to release information form were reviewed on December 17, 2014. The facility failed to verify that the client was offered a copy of the consent in client record #3, 4, 5, 7, and 8.Client #3 was admitted on July 23, 2014 and was still an active client at the time of the inspection. The facility failed to verify that the client was offered a copy of the signed consents for the funding source and the medical center. Client #4 was admitted on January 17, 2014 and was still an active client at the time of the inspection. The facility failed to verify that the client was offered a copy of the signed consents for the medical center and doctor's office. Client #5 was admitted on January 15, 2014 and was still an active client at the time of the inspection. The facility failed to verify that the client was offered a copy of the signed consent for the funding source.Client #7 was admitted on November 5, 2014 and was still an active client at the time of the inspection. The facility failed to verify that the client was offered a copy of the signed consent for the doctor's office.Client #8 was admitted on January 20, 2014 and was still an active client at the time of the inspection. The facility failed to verify that the client was offered a copy of the signed consent for the funding source.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L 0289
This facility will be in compliance with this standard immediately. Identified client charts will be corrected at the next clinical session. The standard Drug & Alcohol Release form is modified to include an offer to the client of a copy of each release. The client will initial either a decline or acceptance of said copy. This POC will be completed by the Project Director.
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709.93(a) 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:
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Observations
Based on a review of client records, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in one of eight client records.The findings included:Eight client records requiring documentation that a comprehensive treatment and rehabilitation plan was developed with the client were reviewed on December 17, 2014. The facility failed to document that an individual treatment and rehabilitation plan was developed with the client in client record # 1.Client # 1 was admitted on February 25, 2014 and discharged on April 10, 2014. The treatment plan was completed by the counselor on March 30, 2014. The treatment plan was not signed by the client; nor was there a progress note indicating the client had participated in the development of his/her treatment plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L 1889
This facility will be in compliance with this standard immediately. The identified client chart will be corrected at the next clinical session. Future treatment plans will be signed by both counselor and client at the time of development, and said development will be documented in that session's progress note. This POC will be completed by the Project Director.
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