INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 13, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, T.W. Ponessa and Associates Counseling Services, 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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709.28 (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 seven client records on May 11, 2021, 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 one record reviewed.
Client #1 was admitted on November 3, 2020 and was still active at the time of the inspection. A consent to release information to a third-party payor dated November 3, 2020 included disclosure of a psychiatric evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1's chart was given to the clinician to follow up with the client, inform them that the consent was not in code with 255.5. The clinician corrected the consents with the client.
The Clinical Director also met with the clinical team on 7/14/21 for group supervision and they discussed the citations found in the audit on the previous day. The Clinical Director reviewed consents with all the clinicians and requested that they review their consents during sessions with their clients.
The Clinical Director will also be having a mandatory training on 8/11/21 for all the clinical staff to review chart paperwork. This will include reviewing the importance of consents and confidentiality. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of seven client records on July 13, 2021, the facility failed to document the purpose of disclosure in two records reviewed.
Client #2 was admitted on March 1, 2021 and was still active at the time of the inspection. A consent to release information to a third-party payor dated March 24, 2021 was signed and dated but had no purpose of disclosure indicated.
Client #4 was admitted on February 25, 2021 and was still active at the time of the inspection. A consent to release information to a third-party payor dated February 25, 2021 was signed and dated but had no purpose of disclosure indicated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director met with the clinician on 7/14/21 of these charts and discussed with her the importance of consents and the need to document all necessary information on them. The clinician was then required to contact these clients and request them to come in to complete new consents and discuss her errors in relation to Code 255.5. This clinician was requested to complete updated consents within a week.
The Clinical Director also met with the clinical team on 7/14/21 for group supervision and they discussed the citations found in the audit on the previous day. The Clinical Director reviewed consents with all the clinicians and requested that they review their consents during sessions with their clients.
The Clinical Director will also be having a mandatory training on 8/11/21 for all the clinical staff to review chart paperwork. This will include reviewing the importance of consents and confidentiality. |