D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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PENNSYLVANIA COUNSELING AND PSYCHIATRIC SERVICES
297 CARE STREET
HARRISBURG, PA 17109

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Survey conducted on 01/09/2015

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection with the record review conducted on January 6-9, 2015 and the physical plant inspection being conducted on January 15, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling and Psychiatric Services was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.	Plan of Correction
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. The consent shall be in writing and include, but not be limited to:
Observations Based on a review of client records, the facility failed to obtain informed and voluntary consents in four of ten records reviewed, and, failed to document whether or not the client was offered a copy of the consent to release in three of ten records reviewed. The findings include: Ten client records were reviewed on January 9, 2015. All were reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in four client records, specifically record, #1, 2, 7 and 10. Client #1 - Consent to release dated October 21, 2014 for the client's pharmacy failed to have the name of the pharmacy listed on the consent to release form. The facility only documented "my pharmacy" on the consent to release form which is not the name of the pharmacy used. Client #2 - Consent to release dated October 2, 2014 for the client's pharmacy failed to have the name of the pharmacy listed on the consent to release form. The facility documented "my pharmacy" on the consent to release form which is not the name of the pharmacy used. Additionally, the facility failed to document whether or not the client was offered a copy of the consent to release dated November 18, 2014 for a government agency. Client #7 - The facility failed to document whether or not the client was offered a copy of the consent to release dated July 9, 2014 for the client's doctor. Client #10 - The facility failed to document whether or not the client was offered a copy of the consent to release dated October 17, 2014 for an agency. These findings were reviewed with facility staff during the licensing process.	Plan of Correction The Facility Director will oversee that all staff are re-educated via staff meeting to complete all consents thoroughly, to include the name of the person, agency, or organization to whom the disclosure is made and to include documentation on whether the client accepted/refused a copy. Office administration will ensure ongoing compliance by checking all releases for completion prior to scanning the documents into the electronic record. The Quality Improvement Department will also monitor for ongoing compliance via random chart audits.