INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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) 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 client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information in one of seven records reviewed.
Client #1 was admitted on April 01, 2025, and was still active at the time of the inspection. There was documentation that information was disclosed to family members during family sessions that occurred on May 15, 2025, June 12, 2025, July 16, 2025, August 7, 2025, August 19, 2025, and October 22, 2025; however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information for the family members involved.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to obtain informed and voluntary consent from the client for the disclosure of information in one of seven records reviewed. Client #1 was admitted on April 01, 2025, and was still active at the time of the inspection. There was documentation that information was disclosed to family members during family sessions that occurred on May 15, 2025, June 12, 2025, July 16, 2025, August 7, 2025, August 19, 2025, and October 22, 2025; however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information for the family members involved. Clinical supervisor will ensure that counselors are obtaining informed and voluntary consent from the client for the disclosure of information for those who are involved in family sessions by checking releases after initial sessions occur by 1/31/2026. This will be monitored through regular file reviews and ongoing staff training by clinical supervisor. The facility will be compliant by 1/31/2026. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent which included the dated signature of the client in one out of seven records reviewed.
Client #6 was admitted on March 14, 2025, and discharged on June 24, 2025. Two informed and voluntary consents from the client for the disclosure of information contained in the client record dated March 19, 2025, for two family members that had a witness signature, but did not include the dated signature of the client. Disclosure had been confirmed during family sessions that occurred on March 19, 2025, April 11, 2025, April 17, 2025, and May 01, 2025.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to obtain an informed and voluntary consent which included the dated signature of the client in one out of seven records reviewed. Client #6 was admitted on March 14, 2025, and discharged on June 24, 2025. Two informed and voluntary consents from the client for the disclosure of information contained in the client record dated March 19, 2025, for two family members that had a witness signature, but did not include the dated signature of the client. Disclosure had been confirmed during family sessions that occurred on March 19, 2025, April 11, 2025, April 17, 2025, and May 01, 2025. The clinical supervisor will ensure counselors are obtaining the dated signature of the client for the disclosure of information on the informed and voluntary consent by reviewing initial paperwork with counselors. This will be monitored through regular file reviews and ongoing staff training by the clinical supervisor. The facility will be compliant by 1/31/2026. |