INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 1, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Chester County Intermediate Unit-Changes 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 a review of client records, the facility failed to include the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of eleven applicable client records reviewed.
Client #13 was admitted to the outpatient activity on October 4, 2024 and was active at the time of the inspection. A release of information form to a physician was signed and dated by the client on September 27, 2024; however, the specific name of the physician, agency or organization was not documented on the form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical supervisor will ensure that name, agency, and organization to whom disclosure will be made is completed on the release of information forms prior to signature. This procedure will be reviewed with clinical staff as well to ensure consistency of compliance with all release of information documentation. |
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 record.
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Observations
Based on a review of patient records, the facility failed to document that a copy of a client consent was offered to the client in three of eleven applicable client records.
Client #1 was admitted to the partial hospitalization activity on January 2, 2024 and was discharged on June 25, 2024. A release of information form to a family member was signed and dated by the client on December 14, 2023; however, there was no documentation in the record indicating a copy of the consent form was offered to the client.
Client #8 was admitted to the outpatient activity on June 25, 2024 and was discharged on August 16, 2024. A release of information form to a family member was signed and dated by the client on December 14, 2023; however, there was no documentation in the record indicating a copy of the consent form was offered to the client.
Client #10 was admitted to the outpatient activity on December 20, 2023 and was discharged on March 22, 2024. A release of information form to an insurance company was signed and dated by the client on December 18, 2023; however, there was no documentation in the record indicating a copy of the consent form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Following a review of the release of information form with the client, the clinical supervisor will ensure that it is indicated on the form that the client either accepted or declined a copy of the form. This procedure will also be reviewed with clinical staff to ensure that this process is completed with each client. |