INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Beal Counseling and Consulting on 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) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form signed and dated by the client prior to the disclosure of information in five out of seven client records reviewed.Client #1 was admitted on May 26, 2021 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated May 26, 2021 for probation and the facility contacted probation via a letter on May 26, 2021, July 20, 2021, and August 17, 2021. A consent to release information was signed by a witness dated May 26, 2021 to the funding source and the facility confirmed that they billed for services. Client #2 was admitted on June 11, 2021and was an active client at the time of the inspection. A consent to release information was signed by a witness dated June 11, 2021 for government agency and the probation officer and the facility contacted government agency and probation via a letter on June 11, 2021. A consent to release information was signed by a witness dated June 11, 2021 to the funding source and the facility confirmed that they billed for services. Client #3 was admitted on June 25, 2021 and was discharged on September 3, 2021. A consent to release information was signed by a witness dated June 25, 2021 for parole. The facility mailed a letter to the parole on June 28, 2021. A consent to release information was signed by a witness dated June 25, 2021 to the funding source and the facility confirmed that they billed for services. Client #4 was admitted on May 20, 2020 and was an active client at the time of the inspection. A consent to release information was signed by a witness dated May 20, 2020 for a drug and alcohol facility. The facility contacted the agency via letter on March 22, 2021. Client #7 was admitted on August 25, 2020 and discharged on October 27, 2020. A consent to release information was signed by a witness dated August 25, 2020 to the funding source and the facility confirmed that they billed for services. These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will document an informed and voluntary consent to release information form signed and dated by the client and staff prior to the disclosure of information. The Project Director will issue a reminder to all staff that all clients must appear in person to sign all consents to release information. The reminder was issued on 11/8/21.
Staff will require Clients to come into the office to sign the Consent to release information. This will occur on 11/8/21. All current Clients were notified that they will need to come to the physical site in order to sign the consent to release information.
All information exchanges and billing will cease until the Consent to release information is obtained.
The Project Director is responsible for monitoring the implementation of the corrective action plan.
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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 the project's policy and procedures manual, the facility failed to inform the clients that the project may not discriminate in the provision of services on the basis of creed which was missing from the client handbook in seven out of the seven client records reviewed.These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director fixed the typographical error and has printed new Client Orientation Handbooks with the word Creed included in them. The policy was correct in the policy and procedure manual. The Newly printed Client Orientation Handbooks will be distributed starting 11/10/2021.
The Counselor providing care will provide the current and all new clients with the revised Client Orientation Handbooks. New clients will indicate their review of this material with a signature on the Consent. Staff will also sign the Consent.
The Project Director will review records monthly to ensure this is occurring. |
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.
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Observations
Based on a review of the project's policy and procedure manual, the facility failed to inform clients that they the right to appeal a decision limiting access to their records to the director in seven out of the seven client ' s records reviewed.These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The policy was updated by the Project Director on 11/9/2021 to reflect the clients right to appeal a decision limiting access to their records. This update has also been added to the Client Orientation Handbook.
The Staff member conducting the Orientation will ensure that the Client handbook is given to the Client and reviewed. The Client will then sign a Consent form indicating that this has occurred. Staff will also sign the Consent.
The Project Director will conduct monthly reviews of records to ensure this requirement is being met.
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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
The facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of proposed type of supportive services in seven out of the seven client records reviewed. These finding were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director has added a section to the treatment plan that will capture the proposed type of supportive services. This was accomplished on 11/9/2021.
All treatment plans and treatment plans reviews will be reviewed by the Project Director to ensure this requirement is met. |