INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Care & Addiction Recovery 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 client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of seven records reviewed.
Client #3 was admitted on March 11, 2024 and was still active at the time of the inspection. There was a letter to a government agency dated April 25, 2024 and there was no consent to release information.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director and the Administrative Assistant discussed the issue regarding the need of a signed consent form prior to the release of any client information to any person or agency immediately following the inspection. All clinical staff will be re-trained individually, and in a staff meeting, by the Project Director to ensure they understand the importance of correct releases to protect client information in areas permitted by the law. Lead Counselor will periodically and randomly inspect client charts to ensure ongoing compliance with the releases. CCARS to be in full compliance by 8/26/24. |
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 a completed informed and voluntary consent which included the purpose of the disclosure in two out of seven records reviewed.
Client #1 was admitted on April 29, 2024 and was still active at the time of the inspection. A consent form dated April 29, 2024 to an outside provider did not list the purpose of the disclosure.
Client #2 was admitted on April 18, 2024 and was still active at the time of the inspection. A consent form dated April 18, 2024 to an outside provider did not list the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Project Director and the Administrative Assistant discussed the issue regarding the need for informed and voluntary consent to include the purpose of the disclosure following the DDAP inspection on 8/13/24. All clinical staff will be re-trained individually, and in a staff meeting, by the Project Director to ensure they understand the importance of accurate releases to include the purpose of disclosure regarding any client information in areas permitted by the law. Lead Counselor will periodically and randomly inspect client charts to ensure ongoing compliance with the releases. CCARS to be in full compliance by 8/30/24. |