INITIAL COMMENTS
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This report is a result of an onsite inspection regarding a complaint investigation conducted on March 14, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the inspection, The Gate House for Men 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 required.
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Plan of Correction
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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 the review of client records, the facility failed to ensure that the information released to the probation and parole office stayed within the limits of 4 Pa. Code, Subsection 255.5(b) in one of one record reviewed.
The findings included:
One patient record was reviewed on March 14, 2012. This record was reviewed for information released to the probation and parole officer. The facility exceeded what was permitted to be released to the probation and parole office in patient record # 1.
A review of patient record # 1 revealed information was released to the probation and parole office on February 1, 2012. The facility released a document titled " Treatment Summary" to the probation officer. The summary of progress related to treatment goals exceeded 4 Pa. Code, Subsection 255. 5 (b). In this summary the counselor documented information that was historical in nature that included events that occurred prior to the client entering treatment. The document detailed the last time the patient used a substance, how many psychiatric facilities the patient attended, medical conditions the client presented, educational history, and job history. Additionally, the summary included where the patient was transferred to upon discharge from the program and informed the probation officer that the patient was told to attend meetings daily. All the aforementioned information exceeded 4 Pa. Code, Subsection 255. 5 (b) which only allows for the probation and parole officer to know the following: whether or not the client is or is not in treatment, client's prognosis, the nature of the project, a brief description of the client's progress, and a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
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Plan of Correction
We have developed a treatment summary that utilizes the 5 allowable areas of Pa. Code, Subsection 255.5 (b). The clinical supervisor will review the utilization of this form with clinical staff during staff meeting. All clinical staff will be attending a training on Practical Applications of Confidentiality. Training will be attended when it is available.
To assure compliance is being maintained, released documents will be reviewed by the Clinical Supervisors prior to being released. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one record reviewed.
The findings include:
Based on the review of one client record on March 14, 2012, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project. The facility did not provide client #1 with a notification in writing.
Client # 1 was admitted to the program on January 19, 2012 and was involuntarily terminated from the program on January 31, 2012. The facility did not notify the client in writing and provide him written reason for his termination from the program.
The finding was confirmed by the clinical supervisor on March 14, 2012 at 1:30 p.m.
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Plan of Correction
The Clinical Supervisors have met and updated the Notification of Involuntary Termination Notice to include signature lines for the client and witness. The notice also includes documentation as to whether the client has received or declined a copy of the notice. The project director has approved the revision. The clinical supervisors will educate the staff on the use of this notice during the weekly staff meeting, and ensure compliance during monthly closed chart reviews. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to inform the client, that they have the opportunity to request reconsideration of the decision for terminating treatment in one of one record.
The findings include:
Based on the review of one client record on March 14, 2012, the facility failed to permit a client to have the opportunity to request reconsideration of the decision to terminate treatment in client record # 1.
Client # 1 was admitted to the program on January 19, 2012 and was involuntarily terminated from the program on January 31, 2012. The facility did not provide the patient the opportunity to request reconsideration of the decision to terminate treatment.
The finding was confirmed by the clinical supervisor on March 14, 2012 at 1:30 p.m.
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Plan of Correction
The Clinical Supervisors have met and updated the Notification of Involuntary Termination Notice to include instructions on the right to request reconsideration. The project director has approved the revision. The clinical supervisors will educate the staff on the use of this notice during the weekly staff meeting, and ensure compliance during monthly closed chart reviews. |