INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of 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) (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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency or organization to whom the disclosure is being made.
Client # 2 was admitted on June 1, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated June 1, 2022 for the purpose of funding did not provide the name of the person, agency or organization to whom the disclosure is being made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is policy for Brighter Visions Counseling to obtain from each client an informed and voluntary consent for the disclosure of information. This is in writing and include but not be limited to: (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). The Facility Director is responsible for the fulfillment of this policy and for this POC which is in effect as of November 17, 2022. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on one of three applicable client records reviewed, the facility failed to provide a complete client record to include case consultations in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate case consultations to occur with every treatment plan update.
Client # 2 was admitted on June 1, 2022 and was still active at the time of the inspection. A treatment plan update occurred on July 29, 2022 and September 27, 2022. There was not a completed case consultation note on those dates.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 6, 2022 annual licensing inspection.
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Plan of Correction
It is policy for the clinical staff of Brighter Visions Counseling to conduct periodic consultations reviewing the case history, treatment goals, treatment response, and continuing treatment plan of each patient. By policy these shall be conducted at a 90 day interval, or preferably at sixty day treatment plan updates. The Facility Director is responsible for the fulfillment of this policy and for this POC which is in effect as of November 17, 2022. |