INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 10, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, A Better Today Inc. was found to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 one of eight client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency or organization to whom disclosure is made.
Client # 1 was admitted on August 13, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated August 13, 2020, did not include the name of the person, agency or organization to whom disclosure is made.
This is a repeat citation from the January 7, 2020 inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 709.28 (c),confidentiality,for Client #1, the informed and voluntary consent that did not include the name of the person, agency or organization to whom the disclosure is made will be obtained. No correspondence with said entity until completed.
Clinical Director and all staff to make sure that all informed and voluntary consents include the name of the person, agency or organization to whom the disclosure is made for all clients.
Clinical staff to obtain proper consent information for all client's moving forward. Clinical Director to monitor client charts to check that consents are filled out properly as well as the correct information to stated entity includes the name of the person, agency or organization to whom the disclosure on a weekly basis. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on three of eight client records reviewed, the facility failed to provide progress notes in correlation with documentation of clinical services on the record of service.
Client # 2 was admitted on August 31, 2020 and was still active at the time of the inspection. The record of service indicated a group session occurred on November 18, 2020. There was not a progress note documented in the client record for that date.
Client # 3 was admitted on October 26, 2020 and was still active at the time of the inspection. The record of service indicated a group session occurred on November 3, 10, 17, and 18, 2020. There was not a progress note documented in the client record for that date.
Client # 5 was admitted on June 15, 2020 and was discharged on September 15, 2020. The record of service indicated a group session occurred on August 13 and September 15, 2020. There was not a progress note documented in the client record for that date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 709.93 (a)(5), there shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following: progress notes.
All client charts (#2, #3, and #5) were reviewed by Clinical Director and counselor of said chart right after inspection/same day. All progress notes were entered into the client(s) charts that were missing and documented correctly.
Clinical Director and clinical staff to ensure client record of service and progress notes match and are not missing in the chart. Clinical Director to monitor this ongoing. |