INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 12, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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 facility failed to document a completed consent to release information in one out of seven records reviewed, as there was a form that was missing required information. Client # 5 was admitted on July 6, 2021 and was still active at the time of the inspection. There was a consent to release form, signed and dated on March 8, 2022, to a mental health provider, but the consent form did not include the specific information to be disclosed. The finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard will be reviewed during our agency staff meeting on June 16, 2022. The proper completion of the required consent forms, including name of person/agency or organization, date, event, specific information disclosed and condition as well as the dated signature of a witness and the expiration date of the consent. Our facility will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that adhered to 42 CFR Part 2. To ensure correct completion of consents forms the Clinical Director and Project Director will verify completion during monthly staff meeting/clinical supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during monthly supervision to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of four records reviewed. Client #4 was admitted to the facility on September 22, 2020 and was still active at the time of the inspection. A treatment plan update was completed on December 23, 2020 and the next update was due no later than February 23, 2021; however the updated treatment plan was not completed until March 2, 2021. Client #7 was admitted to the facility on August 31, 2020 and discharged on February 16, 2021. A treatment plan was developed on October 1, 2020 and the next update was due no later than December 1, 2020; however, there was no update documented in the record at the time of the inspection. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed during our agency staff meeting on June 16, 2022. The Clinical Supervisor and Project Director met with the counselors of client records #4 and 7 to ensure the treatment plan updates will be completed every 60 days as per the agency policy. To ensure completion of treatment plan updates at least every 60 days the Clinical Director and Project Director will verify completion during monthly clinical supervision. The Clinical Supervisor will also review individual counselor's client records on a weekly basis and during weekly supervision to ensure compliance. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of the client records, the facility failed to provide a complete client record, which is to include follow up information in one out of one client records reviewed. Client #7 was admitted to the facility on August 31, 2020, and discharged on February 16, 2021. The client record did not contain documentation of follow up information. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed with all counselors at our staff meeting on June 16, 2022.The proper completion of client documentation of follow-up information. This standard and policy will also be reviewed with all counselors by the Clinical Supervisor during monthly staff supervision to assure compliance. In the future all counselors will bring open and closed charts to monthly supervision and the Clinical Supervisor will verify that the counselors have the completed documentation in the chart.
The Project Director and Clinical Supervisor will also discuss this standard during every mandatory monthly staff meeting and supervision
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