Observations
Based on a review of the facility ' s policy manual, client handbook and client records, the facility failed to develop written policies and procedures on client rights and document written acknowledgement by clients that they had been notified of those rights in three out of three records reviewed.
The facility ' s client rights policy and client rights document in the client records were missing all of the following rights:
(1) A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Corrective Action
The Program Director or Designee will collaborate with IT staff to review the Avatar Client Rights forms for the correct language to utilize in the intake bundle. If there is not a form in Avatar that contains the required language the program will work with IT staff to create a form that meets the criteria.
The ABH SUD Addendum to Individual Rights has been updated to include the required language and it is going through the approval process. Once approved, the updated policy will be shared by the Program Director with staff at the next staff meeting.
The Program Director or Designee will revise the Client Handbook to match the updated policy.
Current clients will be given the new Handbook once it has been revised. All clients will sign off on the attestation page that they received this new handbook. The attestation page will be uploaded and saved to the client chart.
Monitoring
Moving forward any client who is seen for intake will be provided the updated Client Handbook and updated Intake bundle in Avatar. This will be monitored through monthly random chart audits by the Clinical Supervisor to verify updated forms are being utilized.
Proposed Completion Date: 10/02/2026 |