INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Genesis House - Harrisburg 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 and a plan of correction is due on March 24, 2008.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a February 22, 2008 review of client records, the facility failed to obtain an informed and voluntary consent in one of six client records reviewed, #1. Information was released to the client's primary care physician without signed consent.
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Plan of Correction
# 0277 client consent for PCP
Project director will retrain all facility staff on the appropriate completion of PCP client consent process on 3/7/08 to include:
- proper completion of PCP insurance form
- proper completion of associated legal consent form
- proper documentation of collateral contact made with PCP.
Facility director will monitor weekly during regularly chart reviews to ensure consistent completion by 3/10/08. |
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
Based on a February 22, 2008 review of client records, the facility failed to obtain an informed and voluntary consent in three of six records reviewed, # 4, 5 and 6. The specific information to be disclosed to the Federal Bureau of Prisons exceeded the limitations imposed at 4 Pa. Code The specific information to be disclosed included a treatment summary and referral form, substance abuse assessment, mental health assessment, treatment plans, and discharge summaries.
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Plan of Correction
# 0279 Client consent for criminal justice system...
Project director will retrain all facility staff on the appropriate completion of consent to release and the appropriate information which can be legally released to the criminal justice system on 3/7/08.
Project director will also follow up on previous conversations with the Federal Bureau of Prisons staff on 3/7/08 to communicate the issue and our facility's need to limit information given to the Bureau.
Facility director will monitor on a weekly basis by 3/10/08 to ensure compliance. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a February 22, 2008 review of client records, the facility failed to complete treatment plan updates every sixty days in two of five records reviewed, #2 and 5.. The treatment plan up date was 43 days late in client record # 2 and 17 days late in client record # 5.
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Plan of Correction
# 1883 completion of treatment plan updates ...
Project director will retrain all facility staff on the appropriate completion of treatment plan updates including content and time frames of completion per facility policy on 3/7/08.
Facility director will monitor weekly during regular client chart reviews by 3/10/08 to ensure compliance. |