D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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PASSAGES TO RECOVERY, INC.
THE CLASS BULIDING, 1400 SOUTH BRADDOCK AVE, FLR 2
PITTSBURGH, PA 15218

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Survey conducted on 07/27/2021

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on July 27, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Program for Offenders, 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:	Plan of Correction
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.
Observations Based on a review of client records, the facility failed to document a valid consent for the release of information in three of seven client records. Client #1 admitted August 4, 2020 and is currently active. Signed releases expired January 3, 2021 and May 15, 2020. These releases were not updated, yet information was still released. Client #3 admitted July 8, 2020 and is currently active. Signed releases expired July 8, 2021. These releases were not updated, yet information was still released. Client #5 admitted December 11, 2019 and discharged on January 5, 2021. Signed releases expired on December 11, 2020. These releases were not updated, yet information was still released. These findings were reviewed with facility staff during the licensing process.	Plan of Correction An updated consent has already been completed for Client #1 and 3. Going forward, the Primary Therapist will begin to review consents on a consistent basis to ensure that they are not lapsing and the Clinical Director will be following up with monthly chart reviews to ensure that this documentation has been completed and addressed. Further, Therapists have been informed that they can fill out a consent to expire 60 days following discharge as opposed to putting a numerical, calendar date in the expiration slot.