INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on November 16-20, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gaudenzia Erie Inc. Corry Satellite Office 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 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records on November 16-20, 2020, the facility failed to document a completed informed and voluntary consent to release information form in client #7. The forms did not document if the client was offered a copy.
Client #7 was admitted on June 12, 2020 and discharged on October 29, 2020. Four forms all dated June 8, 2020 were to a laboratory, two government agencies and a funding source.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will be informed of the correct way to complete a Consent to Release Information form specifically addressing asking the client if they would like a copy of the Consent to Release Information and checking the appropriate box indicating the client's choice. The Clinical Supervisor will review the releases while completing weekly chart audits and if any erroneous information is found, the Clinical Supervisor will address it with the staff member, new releases will be completed, and the old releases will be voided. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical site inspection on November 20, 2020, the facility failed to display a telephone number viewable to the general public.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A new sign will be made indicating the telephone number. The sign will be legible and large enough to be easily seen. The sign will be placed on the front door to ensure it is viewable to all person's attending the facility. The Program Director will ensure the sign is correct with the days and times of operation and that is it placed on the front door. |