INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 7, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Access and Services Center of Berks County, 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) (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 to on a consent to release information form in three of ten client records reviewed.
Client # 2 was admitted on October 18, 2021 and was discharged on October 18, 2021. There was a release of information form in the client record that was signed and dated by the client and witness on October 18, 2021; however, the form failed to document the name of the person, agency or organization to whom the disclosure would be made.
Client # 4 was admitted on December 2, 2021 and was discharged on December 2, 2021. There was a release of information form in the client record that was signed and dated by the client and witness on December 2, 2021; however, the form failed to document the name of the person, agency or organization to whom the disclosure would be made.
Client # 7 was admitted on October 14, 2021 and was discharged on October 14, 2021. There was a release of information form in the client record that was signed and dated by the client and witness on October 14, 2021; however, the form failed to document the name of the person, agency or organization to whom the disclosure would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the TASC Clinical Supervisor will review all release of information forms on a daily basis. Specifically, the Clinical Supervisor will verify that each form is completed accurately, listing the name of the person and the agency to whom the information may be disclosed. The incorrect release of information forms for the clients in question have been amended. The Clinical Supervisor addressed the issue of completing release of information forms accurately to all staff on an individual and a group basis. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of ten client records reviewed.
Client # 9 was admitted on November 8, 2021 and was discharged on November 8, 2021. The release of information forms to a funding source and a probation officer were signed and dated by the client and witness on November 18, 2021, but both release forms failed to document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, the TASC Clinical Supervisor will review all release of information forms on a daily basis to verify that the specific information to be disclosed is indicated. The Clinical Supervisor has discussed this issue privately with each clinical evaluator/case manager, and emphasized the importance of listing specific information on all release of information forms during a group training on 2.23.2022 |
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 client records, the facility failed to document the purpose of the disclosure on release of information forms in one of ten client records reviewed.
Client # 2 was admitted on October 18, 2021 and was discharged on October 18, 2021. The release of information forms to a funding source and a probation officer were signed and dated by the client and witness on October 18, 2021, but both forms did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective immediately, the TASC Clinical Supervisor will review all release of information forms on a daily basis and verify that a purpose for the disclosure has been indicated. In addition, the Clinical Supervisor has addressed this issue privately with each clinical evaluator/case manager, and emphasized the importance of specifying a recipient and completing the forms accurately during a group training on 2.23.2022. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on an administrative review and a review of client records, the facility failed to include, in their client rights policies and procedures, that the project may not discriminate in the provision of services on the basis of age, color, and marital status. Additionally, the facility failed to document the written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services on the basis of age, ethnicity, color, and marital status in ten of ten client records reviewed.
In each client record reviewed, the client rights acknowledgement form failed to document that the project may not discriminate in the provision of services on the basis of age, ethnicity, color, and marital status.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The TASC Executive Director and Clinical Supervisor successfully amended the Client Rights document in TASC's database system to include additional wording that TASC may not discriminate according to age, ethnicity, color, and marital status. Effective immediately, this revised form is now used by all TASC Clinical Evaluators/Case Managers. The TASC Clinical Supervisor will oversee the proper completion of this document to ensure that all staff and clients are properly informed of TASC's revised non-discriminatory categories. |