INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casa de Consejeria y Salud Integral, 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 complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 2 was admitted on September 20, 2024 and was still active at the time of the inspection. There was evidence 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 any of the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will hold an in-service training to discuss timely revisions and checks of releases of information to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, client and witness signatures and dates. The training will review the correct process in completing releases to include name of the person, agency or organization to whom disclosure is made, and copy of client consent being offered to the client in each release. Active charts will be audited to rectify any ROIs out of compliance and active clients will sign new ROIs as needed. Quality Assurance will continue to audit charts regularly and focus on releases to prevent this from reoccurring.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 4/30/25.
Clinical staff will continue to attend recommended Department of Health trainings and provide documentation in areas such as confidentiality and client record keeping. This will be monitored by the Project Director and the facility director on an annual basis.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure is made on a consent to release information form in two of seven client records reviewed.
Client # 1 was admitted on December 10, 2024 and was still active at the time of the inspection. There was a blank release of information form signed by the client on December 10, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosures would be made.
Client # 4 was admitted on June 17, 2024 and was discharged on November 29, 2024. There was a blank release of information form signed by the client on June 17, 2024; however, the form did not include the name of the person, agency, or organization to whom the disclosures would be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will hold an in-service training to discuss timely revisions and checks of releases of information to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, client and witness signatures and dates. The training will review the correct process in completing releases to include name of the person, agency or organization to whom disclosure is made, and copy of client consent being offered to the client in each release. Active charts will be audited to rectify any ROIs out of compliance and active clients will sign new ROIs as needed. Quality Assurance will continue to audit charts regularly and focus on releases to prevent this from reoccurring.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 4/30/25.
Clinical staff will continue to attend recommended Department of Health trainings and provide documentation in areas such as confidentiality and client record keeping. This will be monitored by the Project Director and the facility director on an annual basis.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in each release of information form in three of seven client records reviewed.
Client # 3 was admitted on December 13, 2024 and was still active at the time of the inspection. There were release of information forms to a laboratory, a funding source, a government agency, a physician, an emergency contact, a transportation company, and a probation and parole officer signed by the client on December 13, 2024; however, there was no documentation that a copy of any of the consent forms were offered to the client.
Client # 5 was admitted on August 6, 2024 and was discharged on February 7, 2025. There were release of information forms to a laboratory, a funding source, a government agency, a physician, an emergency contact, a transportation company, and a probation and parole officer signed by the client on August 7, 2024; however, there was no documentation that a copy of any of the consent forms were offered to the client.
Client # 6 was admitted on October 21, 2024 and was discharged on February 24, 2025. There were release of information forms to a laboratory, a funding source, a government agency, a physician, an emergency contact, a transportation company, and a probation and parole officer signed by the client on October 23, 2024; however, there was no documentation that a copy of any of the consent forms were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will hold an in-service training to discuss timely revisions and checks of releases of information to prevent expiration, lapses of time while a client is active in our program, appropriate completion of whom the release is for, client and witness signatures and dates. The training will review the correct process in completing releases to include name of the person, agency or organization to whom disclosure is made, and copy of client consent being offered to the client in each release. Active charts will be audited to rectify any ROIs out of compliance and active clients will sign new ROIs as needed. Quality Assurance will continue to audit charts regularly and focus on releases to prevent this from reoccurring.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 4/30/25.
Clinical staff will continue to attend recommended Department of Health trainings and provide documentation in areas such as confidentiality and client record keeping. This will be monitored by the Project Director and the facility director on an annual basis.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type of treatment and rehabilitation services on the individual treatment and rehabilitation plan in six of seven client records reviewed.
Client # 1 was admitted on December 10, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 9, 2025; however, the plan did not include documentation of the type of treatment and rehabilitation services to be provided.
Client # 2 was admitted on September 20, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on October 15, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services to be provided.
Client # 3 was admitted on December 13, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 21, 2025; however, the plan did not include documentation of the type of treatment and rehabilitation services to be provided.
Client # 4 was admitted on June 17, 2024 and was discharged on November 29, 2024. The individual treatment and rehabilitation plan was completed on July 18, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services to be provided.
Client # 5 was admitted on August 6, 2024 and was discharged on February 7, 2025. The individual treatment and rehabilitation plan was completed on September 4, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services to be provided.
Client # 6 was admitted on October 21, 2024 and was discharged on February 24, 2025. The individual treatment and rehabilitation plan was completed on December 21, 2024; however, the plan did not include documentation of the type of treatment and rehabilitation services to be provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor along with the facility director will hold an in-service training with all clinical staff to review treatment/recovery plans time frames including PTP within 15 days of admission, CTP within 30 days of admission, and updates every 60 days after. The in-service training will also review the importance of completing and documenting each plan with the client as well as the type of treatment and rehabilitation services to be provided.
The facility director along with quality assurance will conduct weekly reviews of documentation along with compliance reports to ensure adequate clinical document completions and focusing on deficient areas. Completion of in-service will be completed no later than 5/31/2025.
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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 client records, the facility failed to maintain a complete client record, which is to include the documentation of follow-up information, in four of four applicable client records reviewed.
Client # 4 was admitted on June 17, 2024 and was discharged on November 29, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client # 5 was admitted on August 6, 2024 and was discharged on February 7, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 6 was admitted on October 21, 2024 and was discharged on February 24, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client # 7 was admitted on October 14, 2024 and was discharged on February 1, 2025. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In service training will be provided by the Facility Director on compliance documentation submission policy and documentation timeline for all client records to the entire clinical department by May 31, 2025, reviewing and emphasizing on discharges and 30-day follow-ups. This will include the correct process of a discharge and when 30 day follow ups are to be completed.
The facility director will review this Clinical Supervisor to fully address all compliance issues. Quality assurance will conduct regular audits to ensure clinical files, discharges, and follow ups are completed timely.
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