INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection: the physical plant inspection was conducted on January 9, 2025, and record review was conducted on January 16, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services 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 a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of seven records reviewed.
Client #1 was admitted on October 21, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 was discharged on 1/15/25. The Executive Director of Quality Improvement and Director of Outpatient Operations will ensure that staff are re-trained in an upcoming staff meeting to obtain informed and voluntary consents for the disclosure of client information. Staff will be reminded to be especially careful in the event of an insurance change to check the client record and obtain any needed informed and voluntary consent(s) from the client. The Quality Improvement Department will complete quarterly chart reviews to monitor ongoing compliance and re-train as needed. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of two applicable records reviewed.
Client #3 was admitted on August 20, 2024 and was still active at the time of the inspection. A treatment plan was completed on November 6, 2024, and the next update was due no later than January 6, 2025; however, it was not completed until January 10, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director of Quality Improvement and Director of Outpatient Operations will ensure that staff are re-trained in an upcoming staff meeting to document treatment plan updates at least every 60 days. Office Administration will ensure ongoing compliance by tracking completion of treatment plans and ensuring that staff are alerted when treatment plan updates are due. The Quality Improvement Department will also complete quarterly chart reviews to monitor ongoing compliance and re-train as needed. |