INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 5, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in one out of seven records reviewed.
Client #1 was admitted on August 15, 2023 and was still active at the time of the inspection. A consent form dated October 13, 2023 for an outside agency and one on January 5, 2024 to a government agency that failed to include the purpose of the release.
This finding was reviewed with facility staff during the licensing inspection
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Plan of Correction
This will be corrected in several ways. A new release form will be signed by the client at next appointment so that a correct one will be on file. Clinical Supervisor also held a staff meeting this week with all staff explaining the issue and ensuring all staff understand what is required on all release forms. Finally, all release forms will be closely looked at further during weekly documentation audits to ensure they are in compliance. This will be done by either the Clinical Supervisor or Lead Counselor. |