INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 20, 2018 Gaudenzia Inc-Pottsville 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, Gaudenzia Inc.-Pottsville 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 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of seven client records, the facility documented consent to release forms signed by clients that include verbiage stating "I further understand the information specified above will be disclosed pursuant to this authorization, and that the recipient of the information may re-disclose the information and it may no longer be protected by the HIPAA privacy law". This verbiage was in seven of seven client records reviewed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The electronic release of information is currently undergoing revision to address re-disclosure of information and possible lack of protection under HIPPA privacy law. These revisions will be completed by the continuous Quality Improvement Director by 9-1-18 and implemented by 9-1-18. The program Clinical Supervisor will ensure that all revised and approved releases are utilized for each client going forward. Clinical Supervisor will complete monthly quality control chart audits to ensure compliance. |
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 a review of seven client records, the facility failed to document specific information to be disclosed one of seven records reviewed.
Client #2 was admitted on 10/22/17 and was still an active client at the time of the inspection. A consent to release information form dated 01/09/18 to STS did not document specific information to be released.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
An all staff in service training will be held on 8-17-18. PA Code 255.5 will be reviewed. All staff will be reminded that releases must specify what information will be released, as well as to whom. All correspondence documented in the client chart will be monitored monthly by Program Management in the CQI process to ensure compliance. All new clinical hires will be required to enroll in Confidentiality training. Client # 2 has been discharged - unable to obtain appropriate release. A follow up for compliancy will be completed by the Clinical Supervisor by 8-31-18. |