This report is a result of an on-site licensure renewal inspection conducted on November 10, 12, 13, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service and Children's Aid Society 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 December 10, 2008.
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Plan of Correction
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Observations
Based on a review of client records, the facility failed to document an informed consent in two of six client records.The findings include:Six client records were reviewed on November 12, 2008. Informed and voluntary consent to release information forms were required in six client records. Client record #1 included a release of information form for the probation office that had a blank purpose section. Client record #1 also included a progress note that documented a family session with the client and his wife, however, there was no consent to release information form permitting a release of information to the wife. Client record #3 included information that was disclosed to the Venango County Substance Abuse Program, however, there was no consent to release information form permitting a release of information to the Venango County Substance Abuse Program. Client record #3 included an invalid consent to release information form from Children and Youth Services. The Children and Youth Services release form did not include the specific information to be released.
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Plan of Correction
A mandatory staff meeting has been scheduled for 3 PM on December 3, 2008. Both the drug & alcohol program director and clinical supervisor will review this finding with the clinical staff. The chart check procedure will also be reviewed so as to ensure all consents are properly completed and signed, including the currect purpose of the disclosure being checked.
A consent to release information form will be signed prior to anyone else participating in a session with a client. This includes family members who participate in sessions. This will be discussed in the above mentioned mandatory staff meeting. The clinical supervisor will ensure this is being done by a careful review of the client consents when others are particpating in sessions. |