INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 31, 2006 to June 1, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 28, 2006.
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Plan of Correction
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
The annual audit for fiscal year ending December 31, 2004 and 2003 was completed September 9, 2005. Audits need to be completed within six months following the end of the project's fiscal year. This audit should have been completed by June 30, 2005.
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Plan of Correction
709.25(a) -Annual Audit
Director will meet with the board of directors on 6-12-06 to review the standard pertaining to the time frames for completion of the annual audit, reinforcing the due date of June 30th.
Director will secure the annual audit for fiscal year 2005 by June 30, 2006. Previous audits were completed on the CPA's time frame and we will once again reinforce the need to utilize the June 30th time frame.
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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
Client records number 4 and 9 had a Primary Care Physician Follow Up Consent form that does not meet the content requirements for a consent to release information as defined by 28 Pa. Code 709.28 (c)(1-6)(d) or Federal regulations 42 CFR Part 2 Subpart C Subsection 2.31.
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Plan of Correction
709.28(c) - Confidentiality
Director will retrain all facility staff on 6-14-06 on the appropriate confidentiality procedures pertaining to Primary Care Physician contact. Director will reinforce the necessity for the utilization of a standard consent form in addition to that which is utilized by FPH.
Director will monitor compliance via regular client chart reviews during the weekly clinical staff meetings beginning on 6-21-06.
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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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Client record number 4 had a Behavioral Health Concurrent Review Form that included client information regarding medication, treatment history and treatment goals. This information, which was sent to an insurance company, exceeds the limitations on release imposed by 4 Pa. Code subsection 255.5(b). Also, client record number 8 had a discharge report that was sent to a Philadelphia probation officer that exceeded the limitations imposed by 4 Pa. Code subsection 255.5(b) by including the urinalysis results.
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Plan of Correction
709.28(c)(2) - Confidentiality
Director will retrain all facility staff on 6-14-06 on the appropriate completion of concurrent review forms utilized by private insurance carriers and all documents released to outside agencies containing client information. Director will supply a sample copy of appropriately completed forms and review the confidentiality restrictions pertaining to release of client information.
Director will monitor compliance via regular client chart reviews during weekly clinical staff meetings beginning on 6-21-06.
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