INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on December 7, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Bucks County 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
The facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in three of seven applicable client records reviewed.
Client #5 was admitted on October 1, 2019 and was discharged on September 30, 2020. The written policy and procedure manual stated that case consultations will be completed every three months. A case consultation was completed on April 1, 2020 and the next consultation was due no later than July 1, 2020; however, the case consultation was not documented prior to discharge.
Client #6 was admitted on October 21, 2019 and discharged on April 30, 2020. The written policy and procedure manual stated that case consultations will be completed every three months; however, there was no documentation of case consultations during the treatment episode.
Client #8 was admitted on March 25, 2020 and discharged on August 20, 2020. The written policy and procedure manual stated that case consultations will be completed every three months; however, there was no documentation of case consultations during the treatment episode.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon admission, Case consult dates will be entered into calendar with automatic reminder on dates due. Project director will be responsible for entering, monitoring due dates and creating case consult on that date. |
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
The facility failed to obtain a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in one of eight client records reviewed.
Client # 6 was admitted on October 21, 2019 and discharged on April 30, 2020. There was documentation of a disclosure to a law firm 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 disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project manager will assume responsibility for all correspondence to outside entities. Any staff or contractors will be trained or re-trained on the confidentiality statutes 42 CFR Part 2 and 4 Pa. Code § 255.5 |