INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 8, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Lancaster City 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 and a plan of correction is due on February 7, 2009.
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to document a written policy/procedure that shall comply with 4 Pa. Code 255.5
The findings include:
The facility ' s policy and procedure manual was reviewed on January 5, 2009 and January 6, 2009. The facility ' s policy regarding confidentiality of client identity and records included language allowing the facility to disclose information to the parent or guardian of a minor without the minor ' s consent.
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Plan of Correction
The Quality Improvement Department will revise the confidentiality policy to comply with all federal and state confidentiality laws. |
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 shall 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 limit information disclosed to the probation/parole office to the limits set forth in Pa. Code 255.5
The findings include:
Fifteen client records were reviewed on January 8, 2009. A letter/notice was sent to probation/parole which included language stating whether the client still owed a balance in client records #7, 11, 13 and 14.
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Plan of Correction
The Facility Director has revised our Agency Report Form to be compliant with all confidentiality laws. Office administration will distribute and review the new form in staff meeting. The Quality Improvement Department will monitor the implementation of the new form and ongoing compliance with Pa. Code 255.5 via random chart reviews. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document complete aftercare plans in six of seven client records.
The findings include:
Fifteen client records were reviewed on January 8, 2009. Aftercare plans were required in seven client records. The facility did not document aftercare goals that were individualized to each client's needs or that were stated in measurable terms in client records #7, 9, 10, 13, 14 and 15.
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Plan of Correction
The Quality Improvement Department has revised the Aftercare Plan to include prompts to remind therapists to create individualized goals. The QI Department will also be re-educating clinical staff via staff meeting to develop individualized aftercare plans with personal/measurable goals and action steps. QI will then monitor on-going compliance through random chart reviews and re-educate staff as necessary. |