INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 23, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Impact Counseling Services LLC 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 the review of client records, the facility failed to obtain an informed and voluntary consent form for the disclosure of information contained in the client record, in three of seven client records.
Client #1 was admitted on July 16, 2020 and is still an active client. The client's record documented a release for a third-party payer that had not been signed by the client. Correspondence was released to the third-party payer without a valid release.
Client # 2 was admitted on September 8, 2020 and is still an active client. The client's documented a release for a third-party payer that had not been signed by the client. Correspondence was released to the third-party payer without a valid release.
Client # 3 was admitted on February 21, 2020 and is still an active client. The client's record documented a release for a third-party payer that had not been signed by the client. Correspondence was released to the third-party payer without a valid release.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director met with staff to review the need and process for completion of release of information at time of admission. These will be obtained for anyone who we need to have correspondence with about the client. Compliance will be monitored during weekly chart audits.
Clinical supervisor will be responsible for implementing that there is compliance on this issue. The clinical supervisor will meet with the therapists to review cases and consents on a weekly basis at supervision and will do ongoing chart audits. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent form, signed by the client, for the disclosure of information contained in the client's record in three of seven client records.
Client # 1, admitted on July 16, 2020 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 2, admitted on September 8, 2020 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client.
Client # 3, admitted on February 21, 2020 and still an active client, documented releases of information for the disclosure of information that did not include a dated signature of the client.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Project Director reviewed confidentiality regulations and release forms with staff. Educated staff on need for release of information being done and clients signing off on them. Compliance on this will be reviewed during weekly chart audits.
clinical supervisor will do chart audits to ensure correct information is being released. Clinical supervisor will also check for client signatures on the release forms during chart audits and supervisions. |