INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, A.L. Mental Health Counseling PC 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #1 was hired as a Project Director on December 1, 2021 and was due to have the communicable disease trainings no later than December 1, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
704.11 ( c) (1) Mandatory Communicable Disease training:
Plan of correction: The Project Director has attained ( 6 ) hours of HIV/AIDS training as of 03/21/2024 and has a certificate. The Project Director will also attain 4 hours of STD training , Tuberculosis training and training in other health related disorders. Completion date : May 30,2024
The Project Director attended training 08/2023
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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 two records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #2 was admitted on January 19, 2024 was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
2. 709.28 (c) Confidentiality. - no consent to release information form for the funding source .
Plan of correction- Will attach the Release of Confidential Information form that will be utilized for all clients of the Project beginning immediately. Whenever there is a request for information for patient confidential information, this form will be signed by the client and contained in the clients record. Completion date : Immediately, beginning 04/03/2024
Current clients will sign consent forms for funding sources if it missing in their record
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in one out of two records reviewed.
Client #2 was admitted on January 19, 2024 and was still active at the time of the inspection. A consent form dated March 1, 2024 that failed to include the name of the person, agency or organization to whom disclosure is made.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
709/28 ( c) (1) Confidentiality
( failed to document a completed consent to release information form in one or two records reviewed) , and form dated 03/01/2024 failed to include the name of the person , agency or organization to whom disclosure was made - client #2 , PLAN OF CORRECTION: The Project will insure that all specific information that is requested and provided is disclosed and the Consent for Release of Confidential Information that will be attached will be utilized on all patients when there is specific request for the release of confidential information . Completion April 3, 2024
The Project Director will insure that all specific information that is requested and provided is disclosed and the Consent for Release of Confidential information that will be attached will be utilized on all patients when there is a specific request for the release of confidential information
completion April 3, 2024
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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 the review of client records, the facility failed to document a completed consent to release information form in one out of two records reviewed.
Client #2 was admitted on January 19, 2024 and was still active at the time of the inspection. A consent form dated March 1, 2024 failed to include specific information disclosed.
This finding was reviewed with facility staff during the licensing inspection
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Plan of Correction
709.28 (c) (2) Confidentiality March 1, 2024 failure to include specific information disclosed " is completed on all future clients when confidential patient information is released. Consent for Release of Confidential Information will be sent and will be utilized
Completion date April 3, 2024
Include information disclosed on the Consent for Release of Confidential Information on all future clients when confidential information is released.
Consent for Release of Confidential information will be sent and will be utilized .
Completion date - April 3, 2024
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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 the review of client records, the facility failed to document a completed consent to release information form in one out of two records reviewed.
Client #2 was admitted on January 19, 2024 and was still active at the time of the inspection. A consent form dated March 1, 2024 failed to include the purpose of disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
3. 709/28 ( c) (1) Confidentiality
( failed to document a completed consent to release information form in one or two records reviewed) , and form dated 03/01/2024 failed to include the name of the person , agency or organization to whom disclosure was made - client #2 , PLAN OF CORRECTION: The Project will insure that all specific information that is requested and provided is disclosed and the Consent for Release of Confidential Information that will be attached will be utilized on all patients when there is specific request for the release of confidential
information . Completion April 3, 2024
The project will insure that all specific information requested and provided is disclosed and the Consent for Release of Confidential information that will be attached will be utilized on all clients when there is a specific request for the release of confidential information. The purpose for the disclosure will be included on all consent forms.
The project will insure that all current client consent forms include a Purpose Completion
Date: April 3, 2024
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in one out of two records reviewed.
Client #2 was admitted on January 19, 2024 and was still active at the time of the inspection. A consent form dated March 1, 2024 failed to include if the client was offered a copy of the consent.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
4.709.28 (c) (2) Confidentiality March 1, 2024 failure to include specific information disclosed " is completed on all future clients when confidential patient information is released. Consent for Release of Confidential Information will be sent and will be utilized
Completion date April 3, 2024
The project will insure that a copy of the consent form is offered to the client and a copy maintained in the client record. Completion: April 3, 2024
Consent for Release of Confidential Information that will be attached will be utilized on all patients when there is a specific request for the release of confidential information. The purpose for the disclosure will be included on all consent forms. The project will insure that all current client consent forms include a Purpose
Completion date: April 3, 2024
The project will insure that a copy of consent form is offered to the client and a copy maintained in the client record. Completion date April 3, 2024
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement by clients that they have been notified of those rights in one out of one applicable client records reviewed .
Client #2 was admitted on January 19, 2024 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
6. 709.30 Clients Rights
Plan of Corrections. The Project Director is responsible to insure that the client receives an orientation of their client rights ( Policy on clients rights has been developed) and that the client documents written acknowledgement that they have been notified of those rights.
Completion date April 3, 2024
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of two client records, the facility failed to ensure that comprehensive treatment plans included the type and frequency of treatment and services in one of one records reviewed
Client #2 was admitted on January 19, 2024 and was still active at the time of the inspection. The treatment plan was dated January 19, 2024.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
7. 709.92 (a) (2) Treatment and rehabilitation services. Project failed to ensure that comprehensive treatment plans included the type and frequency of treatment and services in one of one records reviewed)
Plan of correction: The project will document , in all patient treatment records, the type and frequency of all treatment and services. The Project Director will spend time reviewing all the treatment requirements that must be document in the patient file, including type and frequency of treatment and services.
Completion date: April 3, 2024 |
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 two client records, the facility failed to document treatment plan updates within the regulatory timeframe in two client records reviewed.
Client #1 was admitted on April 27, 2023 and was discharged January 8, 2024. A treatment plan was completed on April 27, 2023 and the next update was due no later than June 27, 2023; however, no updates were documented in the client record at the time of the inspection.
Client #2 was admitted on January 19, 2024 and was still active at the time of the inspection. A treatment plan was completed on January 19, 2024 and the next update was due no later than March 19, 2024; however, no updates were documented in the client record at the time of the inspection.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
8. 709.92 (B) Treatment and Rehabilitation Services )( Project failed to document treatment plan updates on two patients reviewed within the regulatory timeframe. Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days
Plan of correction The Project Director will ensure that all treatment and rehabilitation plans will be reviewed every 60 days. An electronic reminder will be notify the Director that it is time for the update.
Completion Date April 3, 2024
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709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in one out of one applicable discharged records reviewed.
Client #1 was admitted on April 27, 2023 and was discharged on January 8, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
9. 709/93 ( A) ( 9) client Records - Project failed to provide patient record is to include aftercare information in one of the one applicable discharged records reviewed,
Plan of Correction- The Project Director will insure that the Project's aftercare forms are completed on all discharged clients and will review the standards to reacquaint herself with the mandatory forms
necessary to be completed to insure for a completed client
completion Date April 3, 2024
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709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of one applicable discharged records reviewed.
Client #1 was admitted on April 27, 2023 and was discharged on January 8, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
10.709.93 (A) (10) client Records -project failed to provide complete client record , which is to include discharge summary in one out of one applicable discharged records reviewed.
PLAN OF CORRECTION- The Project Director will insure that Project Discharge Summary forms are utilized on all discharged clients. The project Director will also review all licensing policies pertaining to documentation forms needed in clients folder
COMPLETION DATE : APRIL 3, 2024
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow up information in one out of one applicable discharged records reviewed.
Client #1 was admitted on April 27, 2023 and was discharged on January 8, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.93 clients record. Project failed to provide a complete client record m which is to include follow up information in one of the one applicable discharged records reviewed.
Plan of correction The Project Director will insure that the Projects follow up information forms are completed on all clients and the Project Director will review the licensing mandates for forms that need to be completed in a clients file to consider it as complete record.
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