INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 7, 2024, 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 Service 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) (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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information disclosed in one of seven records reviewed.
Client #5 was admitted on November 9, 2023 and was discharged on April 1, 2024. A release of information form was signed and dated on November 9, 2023, to a medical provider. The informed and voluntary consent form did not have documentation of the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project Director will educate staff on confidentiality and to obtain voluntary consent from the client for the disclosure of information contained in the client records. Project director will monitor this information being obtained by performing chart audits on a monthly basis. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of the disclosure in one out of seven records reviewed.
Client #5 was admitted on November 9, 2023 and was discharged on April 1, 2024. A release of information form was signed and dated on November 9, 2023, to a medical provider. The informed and voluntary consent form did not have documentation of the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Project director will educate staff on obtaining proper release of client information and specifically information for purpose of disclosure. Charts will be reviewed and audited for completion on a monthly basis by project director. |