INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12, 2017 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, RHD- Womanspace 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.
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Observations
Based on the review of 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record #1.Client #1 was admitted on 4/10/17 and was discharged on 5/8/17. There was documentation that a facsimile was sent to an outside agency on 4/17/17; however, the client did not sign a consent to release information form for the agency until 4/25/17.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Documentation of informed and voluntary consent will be completed prior to any client information disclosure, including facsimile communication. Program Director will review and provide instruction on Consent to Release Information policy and procedure to all staff during the next all staff meeting on 7/19/17. All staff will check for or obtain Consent to Release Information documentation before sharing any client information, including via facsimile. Program Director and Assistant Director will monitor the use of Consent to Release Information documentation via chart audit. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include documentation that the facility does not discriminate in the provision of services based on marital status and sexual orientation on the written acknowledgement form that the clients signed in all 7 client records reviewedThese findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Intake Packet, specifically the Civil Rights Compliance form, will be updated by the program, with RHD final approval, to include documentation that RHD Womanspace does not discriminate in the provision of services based on marital status and sexual orientation. This will occur by 8/15/2017. New admissions beginning on 8/15/2017 will sign the updated and RHD approved Civil Rights Compliance Form as part of the intake process. Current clients will review and sign the updated RHD approved Civil Right Compliance Form on 8/15/2017. |
709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document that work done by the client at the project is an integral part of the treatment and rehabilitation plan in all 7 client records reviewed.Client #1 was admitted on 04/10/17 and was discharged on 05/8/17. Client #2 was admitted on 5/11/17 and was discharged on 7/6/17. Client #3 was admitted on 11/17/16 and discharged on 6/16/17. Client #4 was admitted on 7/28/16 and was discharged on 5/24/17Client #5 was admitted on 7/27/16 and was an active client at the time of inspection. Client #6 was admitted on 10/30/16 and was an active client at the time of inspection. Client #7 was admitted on 5/10/17 and was an active client at the time of inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RHD-Womanspace program director will amend the Preliminary, Initial Comprehensive and Updated Treatment Plan templates to include documentation that work done by the clients at Womanspace is an integral part of the treatment and rehabilitation plan. The Assistant Director and Program Director will instruct the clinical team on how to integrate work done by clients at Womanspace into the monthly treatment plans and will audit for future incorporation of work done by the clients into treatment planning. The clinical team will include work done by the clients at Womanspace into all future treatment planning. |