INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 13-15, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, Counseling Solutions of the Lehigh Valley, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of the facility fire drill records between January 2021 and September 2021, the facility failed to document if the fire alarm or smoke detector were operative.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The fire drill procedure form has been updated to include the question of whether the fire alarms and smoke detectors are operative. The form and procedure will be reviewed monthly during fire drills by the Clinical Supervisor or Project Director. The clinical team will be retrained on updated form during the annual in-service. |
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.
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from client for the disclosure of information contained in the client records in seven out of seven records reviewed.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Confirmation of informed consent will be reviewed with each client at the time of intake by the assessor. In order to confirm that this is completed, a quarterly chart review will be scheduled by the Clinical Supervisor. The form and procedure will be reviewed quarterly by the Clinical Supervisor or Project Director. The clinical team will be retrained on updated forms during the annual in-service. Current client forms will be reviewed and updated. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
|
Observations
Based on a review of client records, the facility failed to ensure written acknowledgment that clients have the right to appeal a decision limiting access to their records to the director in seven of seven records.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The client rights have been updated by the Project Director to include that the clients have the right to appeal a decision limiting access to their records to the director. The forms and procedure will be reviewed quarterly by the Clinical Supervisor or Project Director. The clinical team will be retrained on updated forms during the annual in-service. Current client files will be reviewed and updated. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
|
Observations
Based on a review of client records, the facility failed to ensure written acknowledgment that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in seven of seven records.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The client rights have been updated by the Project Director to include that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information. The policy and procedure will be reviewed quarterly by the Clinical Supervisor or Project Director. The clinical team will be retrained on updated policy during the annual in-service. Current client files will be reviewed and updated. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
|
Observations
Based on a review of client records, the facility failed to ensure written acknowledgment that clients have the right to submit rebuttal data or memoranda to their own records seven of seven records.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The client rights have been updated by the Project Director to include that clients have the right to submit rebuttal data or memoranda to their own records. The policy and procedure will be reviewed quarterly by the Clinical Supervisor or Project Director. The clinical team will be retrained on updated policy during the annual in-service. Current client files will be reviewed and updated. |
709.93(a)(1) 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:
(1) Consent forms.
|
Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client records in seven of seven records reviewed.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director has completed a confidentiality and 4 Pa. Code 255.5 review with all staff to confirm that disclosure is within the limits established by 4 Pa. Code 255.5. The form and procedure will be reviewed quarterly by the Clinical Supervisor or Project Director. The clinical team will be retrained on the updated procedure during the annual in-service. The current client's consents will be reviewed and updated. |