INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 2, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Carbon Monroe Pike Drug and Alcohol Commission, 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 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records during Part 2 of the annual licensing inspection on September 2, 20202, the facility failed to document a completed consent to release information form in Client #5's record.
Client #5 was admitted on July 7, 2020 and was still active at the time of the inspection. The consent to release form, dated July 7, 2020, did not include documentation of whether the client was offered a copy.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Supervisor will do weekly chart checks, to include making sure that all Releases of Information are completed correctly, to include documentation that client was offered a copy of the release.
The client was offered a copy of the Release, however the checkbox was missed. |