INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Penndel Mental Health Center 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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709.28 (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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven applicable records reviewed.
Client # 2 was admitted on January 16, 2025 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on May 6, 2024 and the consent form expired on May 5, 2025. There was evidence of disclosures to the funding source after the form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures made after May 5, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility had previously revised policy and procedure to make release of information valid for a 2 year period. This consent was completed near this change of policy. Director will provide retraining to staff on the policy and procedure for making releases/consent valid for a 2 year period of time.
Updated, accurate consents will be completed at the next contact with client #2.
Director/supervisory staff will conduct monthly chart audits to identify and correct any issues moving forward. |
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 a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in two of seven client records reviewed.
Client # 4 was admitted on August 5, 2024 and was discharged on October 1, 2024. The release of information form to the funding source was signed by the client on August 5, 2024; however, the form failed to include the name of the person, agency or organization to whom the disclosure would be made.
Client # 6 was admitted on March 11, 2025 and was discharged on May 5, 2025. The release of information form to the funding source was signed by the client on March 11, 2025; however, the form failed to include the name of the person, agency or organization to whom the disclosure would be made.
This is a repeat citation from the June 20, 2024 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director will retrain current staff on how to correctly and completely complete a release of information. The staff members who completed these releases are no longer with the agency.
Management/supervisory staff will begin reviewing all consents/releases completed upon intake for each new client. |
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 a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of seven client records reviewed.
Client # 4 was admitted on August 5, 2024 and was discharged on October 1, 2024. The release of information form to the funding source was signed by client on August 5, 2024; however, the release form did not include the specific information to be disclosed.
This findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will retrain current staff on how to correctly and completely complete a release of information. The staff member who completed these releases are no longer with the agency.
Management/supervisory staff will begin reviewing all consents/releases completed upon intake for each new client. |
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 a review of client records, the facility failed to ensure a copy of a consent to release information form was offered to the client in one of seven client records reviewed.
Client # 4 was admitted on August 5, 2024 and was discharged on October 1, 2024. The release of information form to the funding source was signed by client on August 5, 2024; however, there was no documentation, in the record, indicating that a copy of the release form was offered to the client.
This is a repeat citation from the July 28, 2021, May 24, 2022, July 6, 2023, and June 20, 2024 annual licensing renewal inspections.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director will retrain current staff on how to correctly and completely complete a release of information. The staff members who completed these releases are no longer with the agency.
Agency has updated the EHR making a copy offered to client a required field on all consents and releases. This will prevent the consent or release form being saved without this being selected. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in four of seven client records reviewed.
Client # 1 was admitted on January 20, 2025 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 24, 2025; however, the plan did not include any proposed type of support services.
Client # 3 was admitted on December 3, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 28, 2025; however, the plan did not include any proposed type of support services.
Client # 5 was admitted on July 30, 2024 and was discharged on January 29, 2025. The individual treatment and rehabilitation plan was completed on August 6, 2024; however, the plan did not include any proposed type of support services.
Client # 6 was admitted on March 11, 2025 and was discharged on May 5, 2025. The individual treatment and rehabilitation plan was completed on March 12. 2025; however, the plan did not include any proposed type of support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will provide training to staff members to include in community supports on each and every treatment plan created. Director will review each treatment plan created to ensure inclusion of in community supports. |
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 maintain a complete client record, which is to include the documentation of an aftercare plan, in two of four applicable client records reviewed.
Client # 5 was admitted on July 30, 2024 and was discharged on January 29, 2025. There was no aftercare plan documented in the record at the time of the inspection.
Client # 6 was admitted on March 11, 2025 and was discharged on May 5, 2025. There was no aftercare plan documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will provide training to staff on the inclusion of aftercare planning for each client. Director will review each discharge for completion of record. |
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 maintain a complete client record, which is to include the documentation of a discharge summary, in two of four applicable client records reviewed.
Client # 5 was admitted on July 30, 2024 and was discharged on January 29, 2025. There was no discharge summary documented in the record at the time of the inspection.
Client # 6 was admitted on March 11, 2025 and was discharged on May 5, 2025. There was no discharge summary documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will provide training to staff on the inclusion of discharge summary for each client upon successful or unsuccessful discharge. aftercare planning for each client. Director will review each discharge for completion of discharge summary. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to ensure the client was offered a copy of a consent to release information form were submitted and approved by the Department for the July 28, 2021, May 24, 2022, July 6, 2023, and June 20, 2024 annual licensing inspections. Failing to ensure a copy of consent to release information forms were offered to the client was again found to be a deficiency in the June 26, 2025 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will institute quarterly reviews, conducted by director, of current POCs to ensure they are being followed. |