INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14 & 15, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service And Children's Aid Society 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 December 14, 2007.
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Plan of Correction
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based upon review of the facility's policies and procedures, the governing body by-laws, and the organizational chart on November 15, 2007, the present project director was not fulfilling the duties of the position as outlined in the Licensing Alert 05-05. The By-laws and policy and procedure manual stated that the Executive Director has the authority to hire the Project Director and that the Project Director reports to the Executive Director who is the person that reports to the Board of Directors. Based upon interviews with the Executive Director and present Project Director, the Executive Director is the person who is presently fulfilling the duties of the position of Project Director and the person who answers to the Board of Directors.
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Plan of Correction
There was a change in Executive Directors. At the time of the exit interview, the licensing specialist took the qualifications of the Executive Director back to DOH to be reviewed. If approved, the current Executive Director will be named the Project Director at the next monthly Board meeting. If it is decided the Executive Director's qualifications do not meet the regulatory standards, the Board of Directors will appoint a person as Project Director who meets the regulatory requirements. |
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 upon review of consent to release information forms in client records on November 16, 2007, the facility failed to ensure that the consents were voluntary and that the client could revoke the consents verbally. The consent forms indicated that the consent could not be revoked if it was signed as a condition of obtaining insurance coverage. The consent forms stated that in order to revoke the authorization that the client had to do so in writing .
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Plan of Correction
Consent forms were already sent to the printer to correct this. Added will be that the client can revoke "verbally or in writing". Until we receive them from the printer, "in writing" will be crossed out with one line & initialed. Once we receive the forms, all old forms will be immediately destroyed so that they can't be used. We anticipate receiving the corrected forms within 2 weeks. |