INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 3, 4, & 5, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mirmont Treatment Center 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 December 8, 2009.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to obtain informed and voluntary consent from the client for the disclosure of information contained in the client record.
Findings:
A review of eleven client records was performed at the facility on November 4 & 5, 2009. In record #11, a letter containing information about the client's treatment and progress had been faxed to an individual in the Delaware County court system. There was no signed or dated voluntary consent from the client authorizing the disclosure to the individual.
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Plan of Correction
The Outpatient Clinical Supervisor will hold an individual supervision session with the counselor who had the deficiency. The Clinical Supervisor will review the policy and procedure for the completion of the informed and voluntary consent form with the counselor. The clinical supervisor will monitor for compliance.
Compliance will be achieved by:
December 15, 2009. |