INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Berks Counseling Center, 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 client records, the facility failed to document the specific information to be disclosed on consent to release information forms in five of seven client records reviewed. Additionally, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (a) for releases of information in two of seven client records reviewed.
Client # 1 was admitted on August 31, 2021 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the client and witness on August 23, 2021, but the release form allowed for the release of "general physical and mental health information", which is not specific enough.
Client # 2 was admitted on October 27, 2021 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the client and witness on October 11, 2021, but the release form allowed for the release of "general physical and mental health information", which is not specific enough.
Client # 3 was admitted on November 25, 2021 and was still active at the time of the inspection. The release of information form to the funding source was signed and dated by the witness on November 24, 2021 and allowed for the release of medication information, lab results and the complete medical record, all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 4 was admitted on May 18, 2021 and was discharged on August 25, 2021. The release of information form to the funding source was signed and dated by the witness on May 18, 2021, but the release form allowed for the release of "general physical and mental health information", which is not specific enough.
Client # 5 was admitted on August 17, 2021 and was discharged on November 8, 2021. The release of information form to the funding source was signed and dated by the client and witness on August 17, 2021, but the release form allowed for the release of "general physical and mental health information", which is not specific enough.
Client # 6 was admitted on April 20, 2021 and was discharged on July 22, 2021. The release of information forms to the funding source and the probation officer were signed and dated by the witness on April 20, 2021 and allowed for the release of the complete medical record, which exceeded the limits established by 4 Pa. Code 255.5.
Client # 7 was admitted on July 15, 2021 and was discharged on October 12, 2021. The release of information form to the funding source was signed and dated by the client and witness on July 15, 2021, but the release form allowed for the release of "general physical and mental health information", which is not specific enough.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clients 1,2,4,5, and 7 were a result of the Shared Consent. The shared consent was based on integrated care. The shared consent has been removed from the admissions process and will no longer be used. A note will be added to shared consents indicating that the release is no longer valid. CQI will monitor for ongoing compliance.
Clients 3 and 6, releases were completed during admission. A review of confidentiality will be completed with the admissions team by 3/31/22 and documented in the huddle minutes. In addition, a prompt will be built into the releases to ensure compliance with DDAP regulations by 4/1/22. In addition, releases will be updated to reflect the proper information to be released by 4/1/22. CQI will monitor charts for ongoing compliance. |
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 client records, the facility failed to document the purpose of the disclosure on release of information forms in three of seven client records reviewed.
Client # 1 was admitted on August 31, 2021 and was still active at the time of the inspection. The release of information form to the emergency contact was signed and dated by the client and witness on August 30, 2021, but the form did not document the purpose of the disclosure.
Client # 2 was admitted on October 27, 2021 and was still active at the time of the inspection. The release of information form to the emergency contact was signed and dated by the client and witness on October 11, 2021, but the form did not document the purpose of the disclosure.
Client # 4 was admitted on May 18, 2021 and was discharged on August 25, 2021. The release of information form to the emergency contact was signed and dated by the witness on July 18, 2021, but the form did not document the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Upon further review, the purpose was missing from the Emergency Consent in the EHR. The consent will be updated to include the purpose by 4/1/22. All other consent will be reviewed to ensure compliance and updated, if necessary, by 4/1/22. When the update to the form is complete, BCC will review and update existing releases for active clients by 5/1/22. CQI will monitor charts for ongoing compliance. |
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 document the dated signature of the client on release of information forms in two of seven client records reviewed.
Client # 4 was admitted on May 18, 2021 and was discharged on August 25, 2021. The release of information forms to a funding source and a government agency were signed and dated by the witness on May 18, 2021 and the release of information forms to a pharmacy and an emergency contact were signed and dated by the witness on July 8, 2021; however, none of the forms documented the dated signature of the client.
Client # 6 was admitted on April 20, 2021 and was discharged on July 22, 2021. The release of information forms to a funding source, a primary care physician, an emergency contact, a parole officer and another treatment provider were all signed and dated by the witness on April 20, 2021; however, none of the forms documented the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Admissions have returned to onsite effective 2/14/22. In scenarios where a client requires virtual care, alternative arrangements will be made for acquiring signatures including but not limited to, mailing documents to the clients, making arrangements to meet them in the community, and acquiring electronic signatures within the DDAP guidelines. CQI will monitor ongoing 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 review and update treatment and rehabilitation plans at least every sixty days in one of three applicable client records reviewed.
Client # 1 was admitted on August 31, 2021 and was still active at the time of the inspection. The individual treatment plan was completed on October 1, 2021 and the first update was due no later than December 1, 2021; however, the update was not completed until January 26, 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
BCC is restructuring Clinical Care Coordination (CCC) services to provide increased oversight to treatment plans. CCC's will take an active role in scheduling treatment plans, inviting families and natural supports, and ensuring integration. The restructure and transition is targeted to be complete by 4/30/22. CQI will monitor for ongoing compliance. |