INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 29, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard 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) (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 disclosure is made on consent to release information forms in seven of seven client records reviewed. Each client record reviewed contained a release of information form to the "probation and parole department"; however, all the forms in every record did not document the specific name of the person, agency, or organization to whom disclosure would be made.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1.The Probation and Parole release will be updated to require the inclusion of the officer's name or the county/state where the probation is in effect.
a. Responsible party -VP Operation?
Completion date ?11-1-2022
2.All staff will receive in-service training on the accurate completion of the form
a. Responsible party -Clinical
Supervisor-Completion date- 1-15-2023
3.The clinical supervisor will conduct a
60 day focus review to insure that
all forms are accurately completed |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire on a consent to release information form in one of seven client records reviewed. Client # 4 was admitted on January 18, 2022 and was discharged on February 19, 2022. The release of information form to an emergency contact was signed by the client on January 18, 2022, but the form did not include the date, event, or condition upon which the consent would expire.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor will retrain the staff on the protocol of documentation related to consent forms i.e. Date, event or condition upon which the consent will expire. All staff will receive the written policy and will sign the attendance sheet verifying that they were trained in the correct protocol.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
2. Clinical Supervisor will add consents to the chart review form that is given to the staff to monitor form completion. This form will be given to the Clinical Supervisor to review during monthly supervision.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
3.Clinical Supervisor will review 30 charts for full completion of consent forms monthly to ensure compliance.
a. Responsible party ?Clinical
Supervisor
Completion date 11/1/2022
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