INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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(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
Based on a review of the client records, the facility failed to document consents to release information which include the name of the person agency, or organization to which the disclosure is made, the specific information to be disclosed, and/or the purpose of the disclosure. The findings include:Five client records were reviewed for consent forms on February 24, 2014. The consents to release information forms did not document all required information in one out of five client records, specifically record # 3. The findings include:Client # 3 was admitted to treatment on April 3, 2013 and discharged on May 31, 2013. A consent form had been signed by the client on April 3, 2013 but it did not specify who the consent would be releasing information to or an expiration date for the consent. The improperly documented release forms were confirmed by the site director prior to the exit interview.
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Plan of Correction
Site Director of the Exton site will conduct an in-services training at the next all-staff meeting on 4-2-2014 regarding confidentiality and compliance with PA code 255.5 regulations. Staff will also be advised to make sure the consent forms are completed "in-full" and at the time of intake. All staff will sign an attendance form for training and that they understand the policy of disclosure and informed consent. The site director of Exton will conduct random monthly chart audits until facility is in full compliance. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two out of two client records.The findings include:Five client records were reviewed on February 24, 2014. Two of those records were required to include documentation of a termination letter. Two of two client records reviewed failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, specifically client records # 3 and 4.Client # 3 was admitted to the program on April 3, 2013 and was involuntarily terminated from the program on May 31, 2013. A letter notifying the client of termination from treatment was not sent until June 17, 2014.Client # 4 was admitted to the program on October 30, 2013 and was involuntarily terminated from the program on December 6, 2013. As of the date of inspection, there was no documentation of written notification to the client.The findings were reviewed with the site director prior to the exit interview.
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Plan of Correction
The site director of the Exton office will begin training immediately through group and individual supervision. An in-service on the proper way to administer follow-up/termination written documentation at time of discharge will be conducted. This training will be held on 4/9/2014 and all Rehab After Work staff at the Exton office are mandated to attend and sign off that they understand the state regulations. The site director will conduct random monthly chart audits until the site is in full compliance. |