INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 9, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Access and Services Center of Berks County, Inc. 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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709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the policy and procedure manual and client records, the facility failed to include in their client rights policy that the project may not discriminate in the provision of services on the basis of marital status. Additionally, the facility failed to document the written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services on the basis of marital status in eight of eight client records reviewed.
In the client rights policy, located in the policy and procedure manual, there was no inclusion of marital status within this client right.
In each client record reviewed, the client rights acknowledgement form did not include documentation that the project may not discriminate in the provision of services on the basis of marital status.
This is a repeat citation from the February 7, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Rights document is stored electronically on TASC's CPR-Web database management system. All clinical staff access this document when conducting screenings and Level of Care assessments with clients. On 2.27.2023 the TASC Clinical Director amended the Client Rights document to include marital status as a category for which TASC may not discriminate. The TASC Executive Director verified that the Client Rights document was amended accordingly and tested the document on that date to ensure that the corrective action was implemented successfully. To ensure that this deficiency does not recur, the TASC Clinical Director is now responsible for reviewing all client documents, including the Client Rights document, on a daily basis to verify that the documents are completed properly. As such, the Client Rights document is inspected daily by the Clinical Director to ensure that it contains the amended language that TASC may not discriminate based upon marital status. The TASC Executive Director reviews a random sampling of documents, including the Client Rights document, on a weekly basis to verify that the corrective action plan has been completed and that the amended Client Rights document is being used. With this process in place, TASC is confident that the deficiency will not recur.
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