INITIAL COMMENTS
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This report is a result of an off-site licensure renewal inspection conducted on January 20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Gaudenzia, DRC, Inc. was found not 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) (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 on January 20, 2021, the facility failed to provide a consent to release form that included specific information to be disclosed.
Client # 1 was admitted on January 12, 2021 and was still an active client at the time of the inspection. Consent forms dated January 12, 2021 to three different labs, two different funding sources, an emergency contact, the Department of Corrections and Probation and Parole did not state what information was to be released.
Client # 3 was admitted on August 31, 2020 and was still an active client at the time of the inspection. Consent forms dated August 31, 2020 to three different labs, two different funding sources, the Department of Corrections and Probation and Parole did not state what information was to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All consent to release information forms will identify specific information to be disclosed.
The Program Director will review consent to release information form to see that the boxes have been checked off appropriately and has the required signatures.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at an Intake Department Staff meeting on February 19, 2021.
The In-service training will explain Specific information to be disclosed: 1. Voluntary consent from the client for the release of information contained in the client record will be in writing and include, specific information to be released. 2. Information pertaining to whether the client is or is not in treatment. 3. Client's prognosis. 4. The nature of the project. 5. A brief description of the client's progress. 6. A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. 7. Other as deemed necessary. This information will be released to labs, funding sources, emergency contact, the Department of Corrections and Probation and Parole will be checked off on the Consent to Release form and signed by the client and staff.
Responsible Person: Outpatient Program Director Target Completion Date: February 19, 2021
Client #1 discharged from the program effective 1/20/21 and the Consent forms to three different labs, two different funding sources, an emergency contact, the Department of Corrections and Probation and Parole that did not state what information was to be released could not be redone.
Client #3 has engaged in telehealth services since being admitted to the program on 8/31/20 and the Consent forms to three different labs, two different funding sources, an emergency contact, the Department of Corrections and Probation and Parole that did not state what information was to be released have not been redone. He will be asked to come into the facility for his next individual session and sign the revised consent forms indicating what information is to be released.
Responsible Person: Outpatient Program Director Target Completion Date: February 19, 2021
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of seven client records on January 20, 2021, the facility failed to provide a consent to release form that included the purpose of disclosure.
Client # 1 was admitted on January 12, 2021 and was still an active client at the time of the inspection. Consent forms dated January 12, 2021 to three different labs, two different funding sources, an emergency contact, the Department of Corrections and Probation and Parole did not state the purpose of disclosure.
Client # 3 was admitted on August 31, 2020 and was still an active client at the time of the inspection. Consent forms dated August 31, 2020 to three different labs, the funding source, the emergency contact, the Department of Corrections and Probation and Parole did not state the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All consent to release information forms will identify purpose of disclosure.
The Program Director will review consent to release information forms to see that the purpose of disclosure is indicated.
The Program Director will facilitate an in-service staff training on completing consent to release information forms at an Intake Department Staff meeting on February 19, 2021
"Gaudenzia DRC Outpatient shall obtain an informed and voluntary consent from the client for the release of information contained in the client record. The consent will be in writing and include the purpose of disclosure. The disclosure is required for the following purposes: 1. To provide funding for ongoing treatment efforts.
2. To obtain insurance or employment of government benefits.
3. To enable judges, attorneys, probation and parole officers to support treatment goals or to make legal decisions on behalf of the client.
4. To coordinate treatment efforts with family, concerned persons and case manager. 5. To coordinate treatment efforts with my employer."
Client #1 discharged from the program effective 1/20/21 and the Consent forms to three different labs, two different funding sources, an emergency contact, the Department of Corrections and Probation and Parole that did not state the purpose of disclosures could not be redone. Responsible Person: Outpatient Program Director Target Completion Date: February 19, 2021
Client #3 has engaged in telehealth services since being admitted to the program on 8/31/20 and the Consent forms to three different labs, two different funding sources, an emergency contact, the Department of Corrections and Probation and Parole stating the purpose of disclosures have not been redone. Client #3 will be asked to come into the facility for his next individual session and sign the revised consent forms indicating the purpose of disclosures.
Responsible Person: Outpatient Program Director Target Completion Date: February 19, 2021
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