INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13-14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family A.C.T.S. Incorporated 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 September 15, 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 the review of five client records on August 14, 2008, the facility failed to document informed and voluntary consent to release information forms in three of three client records where required.
Finding:
The facility did not document consent to release information forms for each third party payer. Consent to release information forms were missing from client records # 1, 2 and 3.
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Plan of Correction
The Facility Director will document client's voluntary consent to release information forms for each and every third party payer as stated under 709.28(c)Licensure. |
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 review of five client records on August 14, 2008, the facility failed to document specific information disclosed on consent to release information forms in three of five client records reviewed.
Finding:
The amount and type of information released to the office of Children, Youth and Families was not listed in a specific manner on the consent to release information forms in client records # 1, 2 and 3. The release forms referred to a monthly report.
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Plan of Correction
The Facility Director will specify the amount and type of information to be released to the Office of Cildren, Youth and Family in addition to any and all other entities that the client's consent to release information has been obtained for as stated under 709.28(c)(2) Licensure. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on review of five client records on August 14, 2008, the facility failed to document the clients' right to have an opportunity to request reconsideration of a decision terminating his/her treatment in one of one client record where required.
Finding:
The termination letter in client record # 5 did not advise the client of his/her right to appeal the decision to terminate treatment.
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Plan of Correction
The Facility Director will add language to notification of termination form advising clients of his/her right to appeal decision to terminate treatment as stated under 709.33(b)Licensure. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on review of five client records on August 14, 2008, the facility failed to document complete drug and alcohol histories in three of three client records where required.
Findings:
The drug and alcohol histories in client records # 1, 2 and 3 were missing the amount and frequency of substances abused. The drug and alcohol history in client record # 1 consisted of contradictory information with no clarification, making it impossible to determine which information was accurate.
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Plan of Correction
The Facility Director will document clear and concise Drug and Alcohol histories to include amount and frequency of substances abused during the intake and admission process as stated under 709.91(b)(3)(ii)Licensure. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on review of five client records on August 14, 2008, the facility failed to document complete personal histories in three of three client records where required.
Finding:
The personal histories in client records # 1, 2 and 3 were missing family history, legal history, educational history, military history, and recreational histories.
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Plan of Correction
The Facility Director will document information regarding the clients personal histories to include family history, legal history, education history, military history and recreational history during the intake and admission process as stated under 709.91(b)(3)(iii)Licensure. |
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 review of five client records on August 14, 2008, the facility failed to document a treatment plan update in one of one client record where required.
Finding:
A treatment plan update was not documented in client record #5.
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Plan of Correction
Teh Facility Director will document treatment plan updates for all clients as stated in 709.92(b)Licensure. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of five client records on August 14, 2008, the facility failed to document a complete aftercare plan in one of one client records where required.
Findings:
The aftercare plan in client record # 4 did not include goals with time frames and a re-entry process.
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Plan of Correction
The Facility Director will document a complete aftercare plan for all clients that will include goals with timeframes and a re-entry process as stated in 7090.93(a)(9)Licensure |
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on review of five client records on August 14, 2008, the facility failed to document a physician signature on comprehensive treatment plans, and treatment plan updates in five of five client records where required.
Finding:
The physician's signature was missing from the treatment plans and treatment plan updates in client records #1, 2, 3, 4 and 5.
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Plan of Correction
The Facility Director will obtain physician signatures for all treatment plans and treatment plan updates as stated in 709.94(g)Licensure. |