INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2019 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, Renewal Treatment, 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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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's policy and procedure manual on October 15, 2019 at the corporate office, the facility failed to include documentation of all the required client rights, including that the facility will not discriminate based on marital status.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc.'s client bill of rights shall document all required client rights, including that the facility will not discriminate based on marital status. All Renewal Treatment, Inc. clients shall be made aware of these rights by signing an acknowledgment that will be maintained in their case record. Renewal Treatment, Inc. has revised it's Client Bill of Rights to include marital status which is included within the body of the Client Consent to Treatment. All Counselor staff have received instruction on this deficiency and the changes that were made to the Client Bill of Rights and Client Consent to Treatment form. Counselor staff shall have all current and future clients sign the new revised Client Consent to Treatment/Client Bill of Rights and place this documentation in the client file. The Clinical Supervisors shall ensure compliance by performing regular internal client file auditing. The Clinical Director and Clinical Supervisors shall have overall oversight responsibilities for this plan of correction. This plan of correction is in place. |