INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2023 through August 17, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Counseling Solutions of the Lehigh Valley, LLC 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 a written informed and voluntary consent from the client for the disclosure of information contained in the client record in three of ten client records reviewed.
Client #1 was admitted on December 7, 2022 and was discharged on March 29, 2023. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #4 was admitted on November 15, 2022 and was discharged on June 2, 2023. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #8 was admitted on February 14, 2023 and was active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This is a repeat citation from the October 15, 2021 and September 9, 2022 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new orientation has been created to prevent recurrence which includes a release for the funding source. This release is to be verified by the Administrative Assistant and the Assessor or Admission Counselor.
Our QA Support will complete a QA review for every active client to confirm that all required releases are present in their charts. if any release needs to be updated, this will be completed by the primary counselor at the client's next individual session. This will be completed by 9/30/2023.
The team member responsible to ensure this POC is implemented is the Clinical Supervisor. |
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 client records, the facility failed to document the purpose of disclosure on release information forms in one of ten client records reviewed.
Client #4 was admitted on November 15, 2022 and was discharged on June 2, 2023. There were release of information forms to a physician and another treatment provider that were signed and dated by the client on November 15, 2022; however, the purpose of the disclosure was not included on either consent to release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Every release will be verified by the witnessing team member during admission to prevent recurrence, where the purpose of the purpose of the disclosure must be clearly stated.
Our QA Support will complete a QA review for every active client to confirm that all required releases are correct in their charts, if any release needs to be updated, this will be completed by the primary counselor at the clients next individual session. This will be completed by 9/30/2023.
The team member responsible to ensure this POC is upheld is the Clinical Supervisor. |
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 a release of information form in one of ten client records reviewed.
Client #5 was admitted on October 25, 2022 and was discharged on January 31, 2023. There was a release of information form to a probation and parole officer; however, the dated signature of the client was not documented on the release form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Every release will be verified by the witnessing team member during admission to prevent recurrence, where the date of the signatures must be clearly stated by both the client.
Our QA Support will complete a QA review for every active client to confirm that all required releases are dated their charts, if any release needs to be updated, this will be completed by the primary counselor at the client's next individual session. This will be completed by 9/30/2023.
The team member responsible to ensure this POC is implemented is the Clinical Supervisor. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in seven of nine applicable client records reviewed.
Client #2 was admitted on November 8, 2022 and was discharged on May 9, 2023. The individual treatment and rehabilitation plan was completed on November 14, 2022, and the first update was due no later than January 14, 2023; however, the update was completed on February 12, 2023.
Client #3 was admitted on November 1, 2022 and was discharged on May 27, 2023. A treatment plan update was completed on January 12, 2023, and the next treatment plan update was due no later than March 12, 2023; however, the update was completed on March 19, 2023. Additionally, the next treatment plan update was due no later than May 19, 2023; however, the update was not completed prior to discharge.
Client #4 was admitted on November 15, 2022 and was discharged on June 2, 2023. A treatment plan update was completed on March 10, 2023, and the next treatment plan update was due no later than May 10, 2023; however, the update was completed on May 20, 2023.
Client #5 was admitted on October 25, 2022 and was discharged on January 31, 2023. The individual treatment and rehabilitation plan was completed on October 25, 2022, and the first update was due no later than December 25, 2022; however, the update was not completed prior to discharge.
Client #6 was admitted on March 17, 2023 and was discharged on August 2, 2023. A treatment plan update was completed on May 17, 2023, and the next treatment plan update was due no later than July 17, 2023; however, the update was not complete prior to discharge.
Client #7 was admitted on January 19, 2023 and was discharged on August 4, 2023. The individual treatment and rehabilitation plan was completed on January 20, 2023, and the first update was due no later than March 20, 2023; however, the update was completed on May 19, 2023. Additionally, the next treatment plan update was due no later than July 19, 2023; however, the update was completed on August 6, 2023.
Client #9 was admitted on January 3, 2023 and was active at the time of inspection. A treatment plan update was completed on May 3, 2023, and the next update was due no later than July 3, 2023; however, the update was completed on August 6, 2023.
This is a repeat citation from the September 9, 2022 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have implemented that every client meets with our Clinical Supervisor or Program Director at minimum once every 60 days to review their progress in treatment and that all documentation is up to date to prevent recurrence. Specifically for treatment plans, a reminder will be sent to each clinician by our QA Support at least 7 days prior to the date that documentation is due.
Our QA Support will complete a QA review for every active client to confirm that all clients have up-to-date treatment plans in the charts, if any treatment plans are overdue, this will be completed by the primary counselor at the client's next individual session. This will be completed by 9/30/2023.
The team member responsible to ensure this POC is implemented is the Clinical Supervisor. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for failing to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the September 9, 2022 and October 15, 2021 annual licensing inspections. Failing to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record was again found to be a deficiency in the August 16 - 17, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To comply with plans of correction that were approved by the Department during the previous inspection. This will be completed by 9/30/2023.
A monthly review of the Plans of Correction will be completed. The team member responsible for ensuring this POC is implemented is the Program Director. |