INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 14-15, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alcohol and Drug Abuse Services, Inc. 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) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information which includes the specific information to be disclosed in one of seven records.
Client #7 was admitted on January 19, 2023 and discharged on January 25, 2023. An informed and voluntary consent dated January 19, 2023 to an agency did not provide the specific information that was to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ON 8/15/23 the Clinical Program Manager sent an email about the importance of specifying the information to be discussed. The clerical will review each consent prior to sending a letter and if the consent is not filled out correctly the letter will not be sent.
The inpatient supervisor will review consents weekly for compliance and the clinical program manager will review monthly. Any concerns will be addressed immediately with staff responsible. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information which included the purpose for disclosure in one of seven records.
Client #7 was admitted on January 19, 2023 and discharged on January 25, 2023. A release of information was signed to an agency on January 19, 2023 which did not indicate the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ON 8/15/23 the Clinical Program Manager sent an email about the importance of identifying the purpose of disclosure. The clerical will review each consent prior to sending a letter and if the consent is not filled out correctly the letter will not be sent.
The inpatient supervisor will review consents weekly for compliance and the clinical program manager will review monthly. Any concerns will be addressed immediately with staff responsible. |
709.28 (c) (6) 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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event, or condition upon which the consent will expire in one of seven client records.
Client #7 was admitted on January 19, 2023 and discharged on January 25, 2023. A release was signed on January 19, 2023 to an agency which did not include an expiration date.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
ON 8/15/23 the Clinical Program Manager sent an email about the importance of listing the expiration date. The clerical will review each consent prior to sending a letter and if the consent is not filled out correctly the letter will not be sent.
The inpatient supervisor will review consents weekly for compliance and the clinical program manager will review monthly. Any concerns will be addressed immediately with staff responsible. |