INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection regarding the plan of correction to the on-site licensure renewal inspection conducted on August 19-20, 2008 and as a follow up to the Show Cause Order issued on February 3, 2009. The follow-up inspection was conducted on May 7, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site follow-up inspection, Samara House of CYWA 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 investigation and a plan of correction is due on June 23, 2009.
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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 five client records on May 7, 2009, the facility failed to obtain an informed and voluntary consent to release information.
Findings were:
Client record #1 contained two consent to release information forms that lacked the clients name and the clients signature, yet information was released to the other treatment center listed on one form and information was provided to the government funding source listed on the other for. The facility released information to a probation office other than the one that they had a signed consent to release information to. The client never completed or signed a consent to release information to the probation office that the information was released to. the information released to probation exceeded 255.5 as it included information regarding drug paraphernalia found in the client's room and items used to cook the drug in the client's room.
Client record #2 contained two consent to release information forms that had the box "other" checked but lacked any documentation of what the other information was. One consent form was to a laboratory and one was to another treatment center.
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Plan of Correction
709.28 (c) Confidentiality The project shall obtain an informed and voluntary consent for the disclosure of information contained in the client record.
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All staff was again trained by the Director on June 15 on Confidentiality and given a copy of the PA Health Department State Regulations as it pertains to confidentiality and release of information (voluntary). CQI and Director will check weekly to ensure all consents are entirely completed and within the regulations of information released and forms are completed in their entirety. To begin June 15, 2009. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a follow-up inspection on May 7, 2009, the facility failed to document that the client was given an opportunity to request reconsideration of a decision termination treatment in two of two client records.
The findings include:
Five client records were reviewed on May 7, 2009. Two client records were terminated from the facility and were required to have documentation that the client was given an opportunity to request reconsideration of a decision termination treatment. The letter of termination in client records #1 and 5 was missing documentation that the client was given an opportunity to request reconsideration of a decision termination treatment.
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Plan of Correction
709.33 (b) Notification of Termination.
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All staff was trained as to the termination policy of 72-hour written notice of discharge and at time of admission all clients will sign off on grievance policy and right to appeal. Training was on June 15, 2009. Director will check each file of clients being discharged to ensure procedures are being followed. Copies of State Regulation 709.33 (b) were given to clinical staff and CQI Coordinator. |