INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, STR Behavioral Health-Lancaster 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 records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of sixteen records reviewed.
Client #2 was admitted to the partial hospitalization level of care on June 19, 2025 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client has since been discharged from the facility.
Director of Quality Assurance and Executive Director retrained staff on release of information protocol and ensuring that all release of informations are in place for clients in services. This training took place on 9/25/25.
Moving forward, Director of Quality Assurance will audit the release of information on a monthly basis. |