INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 24, 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client in four of seven client records.
Client # 1 was admitted on November 5, 2019 and is still an active client. A release for the urinalysis testing laboratory was signed by the client on November 5, 2019. The specific information to be released did not include the patient's urine sample. Urine samples were sent to the laboratory without a valid release.
Client # 2 was admitted on February 20, 2020 and is still an active client. A release for the urinalysis testing laboratory was signed by the client on February 20, 2020. The specific information to be released did not include the patient's urine sample. Urine samples were sent to the laboratory without a valid release.
Client # 3 was admitted on December 5, 2019 and discharged on November 25, 2020. A release for the urinalysis testing laboratory was signed by the client on December 5, 2019. The specific information to be released did not include the patient's urine sample. Urine samples were sent to the laboratory without a valid release.
Client # 4 was admitted on October 1, 2020 and discharged on February 3, 2021. A release for the urinalysis testing laboratory was signed by the client on October 1, 2020. The specific information to be released did not include the patient's urine sample. Urine samples were sent to the laboratory without a valid release.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director met with staff to go over the need for identifying the UDS on release of information for the lab. The UDS release will be for one year and will be renewed yearly.
Clinical supervisor will perform weekly audits of new and existing charts. therapists will obtain proper releases at the tie of admission and will be monitored by their supervisor. |
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.
|
Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client that included the specific information to be released in four of seven client records.
Client # 1 was admitted on November 5, 2019 and is still an active client. A release for the urinalysis testing laboratory was signed by the client on November 5, 2019. The specific information to be released did not include the patient's urine sample.
Client # 2 was admitted on February 20, 2020 and is still an active client. A release for the urinalysis testing laboratory was signed by the client on February 20, 2020. The specific information to be released did not include the patient's urine sample.
Client # 3 was admitted on December 5, 2019 and discharged on November 25, 2020. A release for the urinalysis testing laboratory was signed by the client on December 5, 2019. The specific information to be released did not include the patient's urine sample.
Client # 4 was admitted on October 1, 2020 and discharged on February 3, 2021. A release for the urinalysis testing laboratory was signed by the client on October 1, 2020. The specific information to be released did not include the patient's urine sample.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director reviewed confidentiality with staff and need for UDS to be on releases and renewed yearly. UDS will need to be marked on the release of information for the labs.
Clinical supervisor will ensure that this is corrected and that only the information permitted to be released will be done so. there will be weekly chart audits. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on the review of patient records, the facility failed to provide an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years in two of four patient records.
Patient # 1 was admitted on November 5, 2019. The patient did not receive an average of 2.5 hours of therapy for the months of January, February, March, June, July, August, October 2020.
Patient # 2 was admitted March 5, 2020. The patient did not receive an average of 2.5 hours of therapy for the months of May, June, July, August, September, October, and November 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
project director met with staff on the need for each client on suboxone maintenance to have 2.5 hors of therapy per month during the clients first 2 years of therapy. this will be monitored during chart audits on a weekly basis.
clinical supervisor will ensure corrective action is being implemented and will monitor charts for compliance. |