INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2023, 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:
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Plan of Correction
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709.28 (c) (4) 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:
(4) 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).
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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 dated signature of the client.
Client #5 was admitted on March 23, 2022 and was discharged on December 6, 2022. An informed and voluntary consent for a family member was signed by the therapist on March 23, 2022 but did not include a dated client signature.
This finding was reviewed facility staff during the licensing process.
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Plan of Correction
The project director and facility director will train staff on Confidentiality. they will ensure:(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: (4) 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).
Monthly chart audits will be conducted for compliance. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to have a client orientation to the project which included the hours of operation in all seven records reviewed.
This finding was reviewed facility staff during the licensing process.
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Plan of Correction
The facility will have a client orientation to the project and will include the hours of operation. This will be documented in their files and will be monitored by project director monthly during chart audits. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to have a client orientation to the project which included the fee scheduled in all seven records reviewed.
This finding was reviewed facility staff during the licensing process.
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Plan of Correction
The facility will have a client orientation to the project and will include the fee schedule. This will be documented in their files and will be monitored by project director monthly during chart audits. |