This report is a result of a licensure renewal inspection. The client record review was conducted January 19, 2024, and a physical plant inspection conducted on January 25, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the annual inspection, Pennsylvania Counseling Services, 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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Observations
Based on one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client # 5 was admitted on September 21, 2023 and discharged on December 18, 2023. There was documentation of a family session occurring on November 13, 2023; however, there was not an informed and voluntary consent from the client for the disclosure of information in the client record for the family member.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director of Outpatient Services provided re-education to all clinical and administrative staff that an informed and voluntary consent must be obtained from the client for the disclosure of information, including allowing others to join in a client's session. Re-education was provided on February 6, 2024. The Quality Improvement Department will ensure ongoing compliance via quarterly random chart reviews. |