INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Wyoming Valley Alcohol and Drug Services, 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:
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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 ensure that an informed and voluntary consent to release information was completed accurately in one of ten client records reviewed.
The findings included:
Ten client records requiring complete informed and voluntary consent to release information forms were reviewed on February 1, 2016. The facility failed to ensure that the specific information to be released was completed on the consent to release information form in client record #2.
Client #2 was admitted into treatment on January 5, 2015 and was still an active client at the time of the inspection. A release of information to the emergency contact was signed and dated on 01/05/2015; however; the release of information did not include the specific information to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This was addressed immediately after licensing. Confidentiality was further discussed at the staff meeting that Friday morning. To prevent further issues, confidentiality will be addressed monthly by Clinical Supervisors at staff meetings. Supervisors will ensure accuracy by dissecting files more aggressively. To rectify the situation immediately, a new release of information form will be signed by the client when seen again to make it acceptable. The combination of all these supervisory actions will prevent this specific issue occurring once again in the future. |