INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lehigh Valley Drug and Alcohol Intake Unit 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 April 22, 2009.
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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 a review of client records and staff interview, the facility failed to limit the specific information disclosed to funding sources to that allowable by 4 Pa. Code 255.5 in four of five client records.
The findings include:
Five client records were reviewed on on March 25, 2009. An informed and voluntary consent from the client for the disclosure of information contained in the client record was required in five client records. According to 4 Pa. Code 255.5, the consent to release information forms exceeded specific information to be disclosed in four of five client records reviewed. The evaluation was released to probation in client records #1, 2 and 3. The evaluation was released to the District Attorney's Office in client record #5.
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Plan of Correction
Executive Director will issue a memo by 4/14/09 informing all assessment staff of the deficiencies. Memo to include Confidentiality regulation 4 Pa. Code 255.5 instructing staff on the information allowable to be released. Files will be monitored on a daily basis by the Case Manager to assure compliance. Assessment Staff will be inserviced on Consent to Release forms by May 7, 2009. Case Mgt supervisor and Clinical Director will conduct quarterly chart reviews to assure ongoing compliance.
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709.44(b)(2) LICENSURE Medication Records
709.44. Client records.
(b) If applicable, the project shall also include the following items in the client record:
(2) Medication records.
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Observations
Based on a review of client records, the facility failed to document complete medication records in one of two client records.
The findings include:
Five client records were reviewed on on March 25, 2009. Medication records including the name of the medication, the dosage and the frequency taken was required to be documented in two client records. Client record #2 was missing the dosage of the client's medication and the frequency taken.
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Plan of Correction
Executive Director will issue a memo by 4/14/09 informing all assessment staff of the deficiencies. Memo to include completion of Medication records including the name and dosage. Files will be monitored on a daily basis by the Case Manager to assure compliance. Assessment Staff will be inserviced on Medication records by May 7, 2009. Case Mgt supervisor and Clinical Director will conduct quarterly chart reviews to assure ongoing compliance. |