INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5-7, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Peniel Drug & Alcohol Residential Treatment Facility 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on the physical plant inspection conducted on August 5, 2019, the facility failed to ensure that counseling areas ensured privacy. The counseling office for Staff Person #4, a counselor, had a door with a window in it that allowed persons outside the counselor ' s office to see into the office. A conference room on the first floor is used for counseling, but the door of the office has a window that allows persons outside of the conference room to see into the conference room. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
We have amended our present policy to include blinds in the windows of the office doors mentioned in the deficiency.
The décor throughout this facility is that there are blinds in the office door windows. However, we failed to have blinds installed in the door of the office used by staff #4. The corrective action was completed by our vocational staff before the conclusion of the on-site inspection by installing blinds on the office door window used by staff #4 which prohibits persons outside the counselor's office from seeing into the counselor's office. As far as the conference room is concerned, the vocational staff has also completed the installation of blinds on this door as well, prior to the conclusion of the site inspection which prohibits persons outside the conference room from seeing into the conference room.
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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.
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Observations
Based on a review of client records conducted during the on-site inspection, the facility failed to ensure that it obtained an informed and voluntary release of information for clients prior to disclosing information from client records. Client #1 ' s file had correspondences sent from the facility to a funding source for the months of October, November and December of the year 2018, and the months of January, February, March, April, June and July of the year 2019, but there was no signed consent to release information form from the client for the funding source. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The corrective action was completed by amending our present policy to include an informed and voluntary Release of Information form from the client for the funding source to be signed by appropriate clients during the intake process prior to disclosing information from client records.
Furthermore, all current clients funded by SCA have signed an Authorization to Release Information form which states they agree to the exchange of information between Peniel and the SCA. These forms have been placed in each individual client file by the clinical supervisor.
Client #1 is a former client who had been discharged from treatment at Peniel prior to the site inspection. Therefore, no further action will be taken for client #1 file. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(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.
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Observations
Based on a review of client records conducted during the on-site inspection, the facility failed to obtain documentation from clients that they were informed of all of their rights. At the time of intake, clients sign a form detailing their rights as clients, but the form that they sign does not list creed, religion, marital status, ethnicity or sexual orientation as reasons that clients cannot be discriminated against. These findings were reviewed with facility staff as part of the licensing process.
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Plan of Correction
The corrective action was completed by amending our present Client Rights form to be signed by the client at the time of intake to reflect that no one will be discriminated against on the basis of "age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion." (PA Code 709.30.2)
All current clients have signed the updated Client Rights form, and the signed updated Client Rights forms have been filed in each individual client file by the clinical supervisor. |