INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 8, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Monroe County Counseling, LLC 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) (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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information to be disclosed in one of seven client records reviewed.
Client #6 was admitted on February 29, 2024 and was discharged on April 29, 2024. A release of information form for the court was documented in the client record on February 29, 2024; however, the specific information to be disclosed was not documented on the form.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director carefully reviewed Client # 6's entire chart and signed consent forms that indicated that this was an oversight by the Assessment Counselor/Director. The Project Director annotated a correction to the discharged Client #6 record. In addition, the Project Director has revised the agency's Policies & Procedures regarding all future client records to ensure that all consent forms are reviewed and fully completed immediately after initial assessment. A check?off DDAP note will document same in all future Client records. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on the review of client records, the project failed to include documentation of a disclosure to the client of the criteria for admission, treatment, completion and discharge in seven of seven client records reviewed.
There was no documentation the intake procedures included a disclosure to the client of the criteria for admission, treatment, completion and discharge.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
When a person completes a full drug and alcohol assessment at intake,the MCCS staff is responsible for disclosing to the client the agency's and the client's rights & responsibilities regarding admission, treatment modality, goals of treatment and discharge criteria. Clients are given a Client Handbook and acknowledge this process in an Informed Consent Form. The Project Director has revised the Policy and Procedures Manual so that effective immediately this Assessment/Intake process session is fully documented via a DDAP Progress note in all future records. |