INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Perry Human Services, 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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 7.
Client # 7 was admitted on April 6, 2022 and was discharged September 27, 2022. There was documentation of promise being run on May 18, 2022 and July 11, 2022 in the client records without a valid informed and voluntary consent from the client for the disclosure of information to the Department of Human Services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be addressed on how to complete consent appropriately. They will be provided with training opportunities. Executive Director will perform weekly audits of random charts from each counselor to ensure documentation is properly completed. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 1 was admitted on May 5, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated May 5, 2022 to a county agency did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be addressed on how to complete consent appropriately. They will be provided with training opportunities. Executive Director will perform weekly audits of random charts from each counselor to ensure documentation is properly completed. |
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 two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure
Client # 1 was admitted on May 5, 2022 and was still active at the time of the inspection . An informed and voluntary consent from the client for the disclosure of information dated May 5, 2022 to a county agency did not include the purpose of the disclosure.
Client #3 was admitted on October 31, 2022 and was still active at the time of the inspection. A informed and voluntary consent from the client for the disclosure of information dated December 19, 2022 to an outside provider did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be addressed on how to complete consent appropriately. They will be provided with training opportunities. Executive Director will perform weekly audits of random charts from each counselor to ensure documentation is properly completed. |
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 three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include if the client was offered a copy of the consent.
Client # 2 was admitted on October 26, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 6, 2023 to a PCP, funding source, and governmental agencies did not include if the client was offered a copy of the consent.
Client # 3 was admitted on October 31, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 19, 2022 to an employer, emergency contact, PCP, funding, emergency contact, and governmental agencies did not include if the client was offered a copy of the consent.
Client #5 was admitted on October 20, 2022 and was discharged on January 24, 2023. An informed and voluntary consent from the client for the disclosure of information dated October 20, 2022 to a PCP, emergency contact and government agency did not include if the client was offered a copy of the consent.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Staff will be addressed on how to complete consent appropriately. They will be provided with training opportunities. Executive Director will perform weekly audits of random charts from each counselor to ensure documentation is properly completed. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of one of one applicable client records, the facility failed to report the JDepartment within 3 business days an unusual incident involving death or serious injury due to trauma, suicide, medication error or unusual incident.
Client # 7 was admitted on April 6, 2022 and discharged on September 27, 2022. A progress note in the client record indicated that the client died of an accidental overdose, however this was not reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be addressed on how to complete consent appropriately. They will be provided with training opportunities. Executive Director will perform weekly audits of random charts from each counselor to ensure documentation is properly completed. |