INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Concepts 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed. A fire exit door on the second floor was unable to be opened because of the deck boards being warped.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project will be in full compliance with this standard beginning immediately. The warped boards which were causing the obstruction to the fire exit door were fixed on April 25,2023. The Project Director contacted a contractor who made an appointment to view the deck boards and concluded that they were fixed, and no additional work needed to be completed. This fire exit screen door will also no longer be latched. This standard will be reviewed during our monthly staff meeting on May 17, 2023.
The project was in full compliance with this standard by April 25, 2023. In the future the Project Director will make weekly checks to make sure there is nothing obstructing this exit.
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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 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 # 4 was admitted on December 14, 2022 and discharged on April 17, 2023. An informed and voluntary consent from the client for the disclosure of information dated December 14, 2022 to an emergency contact did not provide the specific information that was to be disclosed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard will be reviewed during our agency staff meeting on May 17, 2023.
The proper completion of the required consent forms, including name of person/agency or organization, date, event, specific information disclosed and condition as well as the dated signature of a witness and the expiration date of the consent. To ensure correct completion of consents forms the Clinical Director and Project Director will verify completion during monthly staff meetings. The Clinical Supervisor will also review individual counselor's client records on a weekly basis.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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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 date, event or condition upon which the consent will expire.Client # 4 was admitted on December 14, 2022 and discharged on April 17, 2023. An informed and voluntary consent from the client for the disclosure of information dated December 14, 2022 to a parole officer did not include the date, event or condition upon which the consent will expire.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard will be reviewed during our agency staff meeting on May 17, 2023. Our facility will obtain informed and voluntary consent from the client for the disclosure of information contained in the client record. The proper completion of the required consent forms, including date, event, and condition as well as the expiration date of the consent.
To ensure correct completion of consent forms the Clinical Director and Project Director will verify completion during monthly staff meetings. The Clinical Supervisor will also review individual counselor's client records on a weekly basis.
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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 one of seven client records reviewed, the facility failed to provide documentation in the client record that an informed and voluntary consent from the client for the disclosure of information was offered to the client.Client # 4 was admitted on December 14, 2022 and discharged on April 17, 2023. An informed and voluntary consent from the client for the disclosure of information dated December 14, 2022 to a parole officer did not provide documentation it was offered to the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard will be reviewed during our agency staff meeting on May 17, 2023. The proper completion and documentation that the client was offered a copy of the informed and voluntary consent form will begin immediately. To ensure correct completion of consent forms the Clinical Director will verify completion during monthly staff meetings. The Clinical Supervisor will also review individual counselor's client records on a weekly basis. |
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 one of one applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur 60 days after discharge by phone.Client # 5 was admitted on August 26, 2022 and was discharged on November 3, 2022. There was no follow-up information available in the client record. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the April 12, 2022 annual licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed with all counselors and support staff during our monthly staff meeting on May 17, 2023. The proper completion of client documentation of follow-up information. Beginning immediately, the follow-up contact information and letter to be sent to the client after 60 days will be given to support staff who will keep information in a binder and will send out letters at the end of 60 days. To ensure correct completion of consent forms the Clinical Director will verify completion during monthly staff meetings. The Clinical Supervisor will also review individual counselor's client records on a weekly basis. |