INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 18, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, LaRocco Counseling 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) 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.
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Observations
Based on two of seven 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 in client records # 1 and # 7.
Client # 1 was admitted on October 5, 2021 and was still active at the time of the inspection. Information to a lab was released on November 2, 21, December 9, and 15, 2021 without an informed and voluntary consent from the client for the disclosure of information.
Client # 7 was admitted on May 10, 2021 and was discharged on July 16, 2021. A fax allowing demographics and name of treatment facility dated June 4, 2021 to a housing program was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Ct 1: LaRocco Counseling Inc is in the process of completing a Qualified Service Organization/Business Associate Agreement with Redwood Laboratory to meet the guideline for confidentiality. In the meantime, clients are signing individual releases of information to specimens sent to Redwood Laboratory.
Ct 7:
LaRocco Counseling Inc will obtain and double check all releases of information prior to communication with any entity regarding client information. This was already reviewed with staff will be monitored closely through internal audits. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 1 was admitted on October 5, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a medical facility signed dated October 5, 2021 did not include the specific information disclosed.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 15, 2021 annual licensing inspection.
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Plan of Correction
LaRocco Counseling Inc will be re-training staff on documentation regarding release of information, with a focus on being specific in the intention and purpose of the release and what information will be released. This will also be reviewed in internal audits and addressed ongoing in staff meetings. |
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 three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 1 was admitted on October 5, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a medical facility signed and dated on October 5, 2021 did not include the purpose of the disclosure.
Client # 3 was admitted on August 3, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to another facility signed and dated on August 3, 2021 did not include the purpose of the disclosure.
Client # 7 was admitted on May 10, 2021 and was discharged on July 16, 2021. An informed and voluntary consent from the client for the disclosure of information signed and dated May 10, 2021 to a parole officer did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LaRocco Counseling Inc will be re-training staff on documentation regarding confidentiality and release of information; with the focus being specific on the documentation of the purpose of disclosure, and making sure it is documented on the release of information. This will also be reviewed in internal audits and addressed ongoing in staff meetings. |