INITIAL COMMENTS
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709.14 Restriction on License (a)(5) Authorized capacity.
On June 10, 2008, the facility had a census of 51 for the outpatient activity which exceeds the authorized maximum capacity of 50.
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Plan of Correction
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709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on the facility inspection on 6-9-08, closed client records are stored with all of the agency closed records. This allows unauthorized staff access to the drug and alcohol client records.
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Plan of Correction
Within 30 days the Erie office manager will remove all closed drug and alcohol files from the file cabinets containing regular closed counseling records. The closed drug and alcohol records will then be placed in separate locked file cabinets. These file cabinets will be located in the office of Erie office manager to insure additional checks that only authorized staff members have access to drug and alcohol record files. The move of these records will be supervised by the facility director to make sure all closed drug and alcohol files are moved into their own locked file cabinets. |
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 6-10-08, the facility failed to have a client sign a release of information prior to the disclosure of information. There was no documentation of a consent to release information form to the funding source in client record #3, though a release of information to that funding source was made. Client record #1 contained documentation of an outdated release of information form that was an invalid consent to release information.
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Plan of Correction
Within 30 days the Erie office manager will remove all outdated release forms from the office form room. The facility director will meet will all drug and alcohol counselors within the next three weeks to review Chapter 709, Subchapter C. General Standards for Free-Standing Treatment Activities, specifically 709.28 Confidentiality and the appropriate use and completion of client releases of information. The facility director will then be responsible for checking all new and existing drug and alcohol cases to insure appropriate releases have been obtained before the releasing of any additional client information to funding sources. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based upon a review of the client census lists provided on June 10, 2008 and on discussions with the facility director on that same date, the facility failed to ensure that the data collection and record keeping system provided for the efficient retrieval of data. The lists provided for the inspection were inaccurate and the facility could not provide more accurate documents during the inspection.
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Plan of Correction
Effective immediately, agency protocol has been changed that all drug and alcohol cases are to be closed in the agencies data collection system on the day they are given to the office manager. Prior policy was that cases were closed in the system only after discharge summaries had been typed by the office manger, the summaries had been read and approved by the facility director, and any needed typographical corrections were made to the summary. These actions will now take place after the case has been officially closed in the data management system. |
INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9 -10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Counseling and Adoption Services, 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 and a plan of correction is due on July 9, 2008.
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Plan of Correction
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709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based on a review of 5 client records on 6-10-08 it was determined that two of those records were required to have discharge summaries. The facility failed to provide a date for the completion of treatment on the discharge summary. The date included on the discharge summary is the date it was typed, not the date the client completed treatment. It was not possible to determine if the summary was completed within seven days of the discharge date. This documentation error was found in two of two records reviewed where the discharge summary was required, specifically client records # 4 and 5.
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Plan of Correction
Effective immediately, the office manager will no longer put the date that discharge summaries were typed by the office manager under the drug and alcohol counselors signature, but the date that the drug and alcohol counselor either wrote or dictated the discharge summary. As discharge summaries currently have the date the client completed treatment, by now showing the date the report was written/dictated, it will be possible to determine the time frame between the date the client completed treatment and the completion of the discharge summary. |