INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29-31, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cen-Clear Child 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:
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Plan of Correction
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the name of the person, agency or organization to whom the disclosure is being made.
Client # 3 was admitted on November 22, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 22, 2021 for the purpose of an emergency contact did not provide the name of the person, agency or organization to whom the disclosure is being made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The identified ROI will be corrected at the consumers next scheduled session on 4/14/2022 by the therapist obtaining a new ROI with the correct information. When obtaining an ROI for the Emergency Contact the staff (Therapist, Clinical, or Navigator) completing this task will provide the name of the person, agency, or organization to whom the disclosure is being made to. This will also be reviewed by the assigned Navigator at the time of approval for the ROI to ensure that this information is included. If it is not a new ROI will then need to be obtained containing this information. This process is currently in place and will be reviewed in the next site meetings occurring he week of 4/11/2022 - 4/15/2022. |
709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of one of one applicable client records, the facility failed to report the department within 3 business days an unusual incident involving an outbreak of a contagious disease requiring CDC notification.
Client # 7 was admitted on August 23, 2021 and discharged on January 10, 2022. A progress note in the client record indicated a positive Covid 19 test had occurred however, this was not reported to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients that report a positive COVID-19 test will be reported to the department through the online unusual incident reporting system. This information will be sent to Regional Director and Administrative Manager from the staff that was informed by the client. Administrative Manager will then enter the information into the system. |