INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9 and 10, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Freedom Recovery Center, LLC 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #4 received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee #4 was hired as a support staff on May 1, 2020 and was still in this position at the time of the inspection. Employee #4 was due to have the HIV/AIDS training no later than May 1, 2022. There was no documentation in the personnel file of the completion of the HIV/AIDS training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director met with the Human Resource Manager and the Compliance Officer to ensure that all new employees, clinical or clerical complete their HIV/AIDS and BASIC HIV training within the time frame outlined in compliance with 704.11 (c) (1). Starting August 22, 2022, the Compliance Officer will monitor and track that trainings have been completed in compliance with 704.11 (c) (1). |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 3 was admitted on June 9, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated June 9, 2022 to a funding source did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director met with the Human Resource Manager and reviewed the Consents to Release information in accordance with 709.28 (c) (2). The HR Manager ensured that all consents will be completed in compliance with Confidentiality 709.28 (c) (2). The Project Manager will monitor compliance through reviewing of the client charts starting August 22, 2022. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client # 3 was admitted on June 9, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated June 9, 2022 to a funding source did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director met with the Human Resource Manager and reviewed the Consents to Release information in accordance with 709.28 (c) (3). The HR Manager ensured that all consents will be completed in compliance with Confidentiality 709.28 (c) (3). The Project Manager will monitor compliance through reviewing of the client charts starting August 22, 2022. |