INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16-17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. Based on the findings of the on-site inspection, Alcohol and Drug Abuse 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) (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 the review of client records, the facility failed to document a completed consent to release information form in one out of seven records reviewed, as the form permitted "other" without specifying what other information may be released.
Client #5 was admitted on March 16, 2021 and was still active at the time of the inspection. The consent form was to a doctor's office.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
1. As of 9/20/2021 at 3pm the clinical supervisor sent an email to all the outpatient staff the findings of the licensing visit. Instructions were given as to how to complete a consent correctly and the importance of documenting information if other is specified.
2. On 10/6/2021 the clinical supervisor and clinical staff in facility 427-034 reviewed every active client file to ensure consents were completed correctly. They all were.
3. On 10/7/21 the outpatient staff were advised that during routine monthly chart reviews the clinical supervisor and outpatient counselors will review consents to ensure they are completed correctly.
4. The chart reviews from the previous month will be discussed at monthly outpatient department meetings (outpatient counselors, clinical supervisor). These occur the 1st Thursday of each month. Any discrepancies will be addressed immediately.
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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, as the form did not have a purpose listed.
Client #6 was admitted on April 19, 2021 and was still active at the time of the inspection. The consent form was to an attorney.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
. As of 9/20/2021 at 3pm the clinical supervisor sent an email to all the outpatient staff the findings of the licensing visit. Instructions were given as to how to complete a consent correctly and importance of being sure to indicate the purpose of the consent.
2. On 10/6/2021 the clinical supervisor and clinical staff in facility 427-034 reviewed every active client file to ensure consents were completed correctly. They all were.
3. On 10/7/21 the outpatient staff were advised that during routine monthly chart reviews the clinical supervisor and outpatient counselors will review consents to ensure they are completed correctly.
4. The chart reviews from the previous month will be discussed at monthly outpatient department meetings (outpatient counselors, clinical supervisor). These occur the 1st Thursday of each month. Any discrepancies will be addressed immediately.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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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, as the form did not include a date, event or condition upon which the consent will expire.
Client #7 was admitted on April 27, 2021 and was still active at the time of the inspection. The consent form was dated March 25, 2021 to a family member.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
. As of 9/20/2021 at 3pm the clinical supervisor sent an email to all the outpatient staff the findings of the licensing visit. Instructions were given as to how to complete a consent correctly and the importance of including an expiration date on all consents.
2. On 10/6/2021 the clinical supervisor and clinical staff in facility 427-034 reviewed every active client file to ensure consents were completed correctly. They all were.
3. On 10/7/21 the outpatient staff were advised that during routine monthly chart reviews the clinical supervisor and outpatient counselors will review consents to ensure they are completed correctly.
4. The chart reviews from the previous month will be discussed at monthly outpatient department meetings (outpatient counselors, clinical supervisor). These occur the 1st Thursday of each month. Any discrepancies will be addressed immediately.
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