INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Impact Counseling Services, LLC. was found to be not 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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709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Eight client records were reviewed on September 13, 2017. The facility failed to document the following provision on the client rights form in client records #2, 6, 7 and 8:
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Project director trained staff on new forms that were revised on 10/1/17. The charts will be checked weekly for compliance via random chart reviews done so by the project director. Old forms were disposed of and new forms are now put into place.Staff have been trained on patient rights and were made aware of addition to patient rights to include Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Eight client records were reviewed on September 13, 2017. The facility failed to document the following provision on the client rights form in client records #2, 6, 7 and 8:
(4) Clients have the right to appeal a decision limiting access to their records to the director.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Project director trained staff on new forms that were revised on 10/1/17. The charts will be checked weekly for compliance via random chart reviews done so by the project director. Old forms were disposed of and new forms are now put into placeStaff were trained and forms were changed for patient bill of rights to include that Clients have the right to appeal a decision limiting access to their records to the director. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Eight client records were reviewed on September 13, 2017. The facility failed to document the following provision on the client rights form in client records #2, 6, 7 and 8:
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Project director trained staff on new forms that were revised on 10/1/17. The charts will be checked weekly for compliance via random chart reviews done so by the project director. Old forms were disposed of and new forms are now put into place.Staff were trained on and patient bill of rights form were changed to reflect Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
This information was reviewed with the facility staff during the licensing inspection. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Eight client records were reviewed on September 13, 2017. The facility failed to document the following provision on the client rights form in client records #2, 6, 7 and 8:
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Project director trained staff on new forms that were revised on 10/1/17. The charts will be checked weekly for compliance via random chart reviews done so by the project director. Old forms were disposed of and new forms are now put into place.Staff were trained on and patient bill of rights forms were changed to reflect Clients have the right to submit rebuttal data or memoranda to their own records |