INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 7, 2006 and April 10, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on May 29, 2006.
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Plan of Correction
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709.81(b)(3)(ii) LICENSURE Intake and admission
709.81. 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
The lengths and patterns of use should include a clear progression of the client's substance use/abuse, but the progression was not clearly defined in client records #1, 2,and 3. Closed client record #4 was missing the drug and alcohol history.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.83(a)(10) LICENSURE Client records
709.83. 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
Discharge summaries were missing in client charts #1 and 3.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.83(a)(11) LICENSURE Client records
709.83. 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:
(11) Follow-up information.
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Observations
Follow up was not consistently documented in all client records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
Parent/guardian signature lines were included on the consent to release information forms in client records #2, 8 and 10. Minors in Pennsylvania have the right to seek treatment on their own, without parental consent. Federal regulations at 42 CFR Part 2, Subpart B, subsection 2.14(b) specify that in states where minors may seek treatment on their own, without parental consent, only the minor can consent to the release of information. The purpose for releases of information were not listed in client records #6, 9, and 10.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.31(a) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(a) If a project utilizes Department funds, it shall comply with the Department's UDCS.
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Observations
The record retrieval process during the licensing inspection was inefficient. Agency policy regarding storage of closed records at the main sit was not consistently followed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Follow up was not consistently documented in the client records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |