INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casa De Consejeria Drug and Alcohol Counseling Program, Inc 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 in one of seven client records reviewed.
Client # 2 was admitted on October 3, 2024 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will hold an in-service training to discuss timely revisions and checks of releases of information to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, client and witness signatures and dates. The training will review the correct process in completing releases to include name of the person, agency or organization to whom disclosure is made, and copy of client consent being offered to the client in each release. Active charts will be audited to rectify any ROIs out of compliance and active clients will sign new ROIs as needed. Quality Assurance will continue to audit charts regularly and focus on releases to prevent this from reoccurring.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 4/30/25.
Clinical staff will continue to attend recommended Department of Health trainings and provide documentation in areas such as confidentiality and client record keeping. This will be monitored by the Project Director and the facility director on an annual basis.
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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 document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in three of seven client records reviewed.
Client # 1 was admitted on August 22, 2024 and was still active at the time of the inspection. There was a blank release of information form and a release of information form to the emergency contact signed by the client on August 22, 2024; however, both forms did not include the name of the person, agency, or organization to whom the disclosures would be made.
Client # 3 was admitted on September 10, 2024 and was still active at the time of the inspection. There was a blank release of information form and a release of information form to the emergency contact signed by the client on September 10, 2024; however, both forms did not include the name of the person, agency, or organization to whom the disclosures would be made.
Client # 7 was admitted on August 14, 2024 and was discharged on December 31, 2024. There was a blank release of information form and a release of information form to the emergency contact signed by the client on August 14, 2024; however, both forms did not include the name of the person, agency, or organization to whom the disclosures would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will hold an in-service training to discuss timely revisions and checks of releases of information to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, client and witness signatures and dates. The training will review the correct process in completing releases to include name of the person, agency or organization to whom disclosure is made, and copy of client consent being offered to the client in each release. Active charts will be audited to rectify any ROIs out of compliance and active clients will sign new ROIs as needed. Quality Assurance will continue to audit charts regularly and focus on releases to prevent this from reoccurring.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 4/30/25.
Clinical staff will continue to attend recommended Department of Health trainings and provide documentation in areas such as confidentiality and client record keeping. This will be monitored by the Project Director and the facility director on an annual basis.
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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 client records, the facility failed to include documentation that a copy of a client consent was offered to the client in each release of information form in four of seven client records reviewed.
Client # 1 was admitted on August 22, 2024 and was still active at the time of the inspection. There were release of information forms to a laboratory, a funding source, a government agency, a physician, an emergency contact, a transportation company, and a probation and parole officer signed by the client on August 22, 2024; however, there was no documentation that a copy of any of the consent forms were offered to the client.
Client # 3 was admitted on September 10, 2024 and was still active at the time of the inspection. There were release of information forms to a laboratory, a funding source, a government agency, a physician, an emergency contact, a transportation company, and a probation and parole officer signed by the client on September 10, 2024; however, there was no documentation that a copy of any of the consent forms were offered to the client.
Client # 5 was admitted on July 29, 2024 and was discharged on January 31, 2025. There was a release of information form to a government agency signed by the client on July 29, 2024; however, there was no documentation that a copy of the consent form was offered to the client.
Client # 7 was admitted on August 14, 2024 and was discharged on December 31, 2024. There were release of information forms to a laboratory, a funding source, a government agency, a physician, an emergency contact, a transportation company, and a probation and parole officer signed by the client on August 14, 2024; however, there was no documentation that a copy of any of the consent forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will hold an in-service training to discuss timely revisions and checks of releases of information to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, client and witness signatures and dates. The training will review the correct process in completing releases to include name of the person, agency or organization to whom disclosure is made, and copy of client consent being offered to the client in each release. Active charts will be audited to rectify any ROIs out of compliance and active clients will sign new ROIs as needed. Quality Assurance will continue to audit charts regularly and focus on releases to prevent this from reoccurring.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 4/30/25.
Clinical staff will continue to attend recommended Department of Health trainings and provide documentation in areas such as confidentiality and client record keeping. This will be monitored by the Project Director and the facility director on an annual basis.
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