INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 10, 11 & 12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Butler Regional Recovery Day Program 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 June 8, 2010.
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Plan of Correction
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711.83(c)(3) LICENSURE Client's Copies of Consents
711.83. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a discussion with the facility director, a review of the consent to release information form and a review of client records on May 10 through 11, 2010, the facility failed to document that a copy of the consent to release information form was offered to and/or accepted or rejected by the client.
The findings include:
Four patient records were reviewed on May 10 through 11, 2010. Four records were reviewed for documentation that the consent to release information form had been offered to the client and accepted or rejected. Records # 1, 2, 3, and 4 did not contain documentation that the client was offered a copy of the consent form and if it was accepted or rejected.
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Plan of Correction
The Facility Director will review and modify the Release of Information Form to incude a check box to indicate that a copy was offered to the client and if the copy was rejected or accepted. The form will then be sent to administration and be printed. While waiting for the new release, the counselor will document in the chart that a copy was offered to the client and if the client rejected or accepted it. this will take place immediately as of todays date of 5/21/10. |
711.93(c)(3) LICENSURE Copy-Client Consent
711.93. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a discussion with the facility director, a review of the consent to release information form and a review of client records on May 10 through 11, 2010, the facility failed to document that a copy of the consent to release information form was offered to and/or accepted or rejected by the client.
The findings include:
Three patient records were reviewed on May 10 through 11, 2010. Two records were reviewed for documentation that the consent to release information form had been offered to the client and accepted or rejected. Records # 5 and 6 did not contain documentation that the client was offered a copy of the consent form and if it was accepted or rejected.
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Plan of Correction
The Facility Director will review and modify the Release of Information Form to incude a check box to indicate that a copy was offered to the client and if the copy was rejected or accepted. The form will then be sent to administration and be printed. While waiting for the new release, the counselor will document in the chart that a copy was offered to the client and if the client rejected or accepted it. This will take place immediately as of todays date of 5/21/10. |