INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 12, and 13, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Fayette County Drug and Alcohol Commission 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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.Client # 2 was admitted on December 13, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 13, 2021 to a government agency did not provide the specific information that was to be disclosed. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Consent form requirements will be reviewed in Unit Staff meeting on 8/2/2022. A minimum of 5 charts will continue to be reviewed monthly by Treatment Supervisor and Lead counselor will conduct weekly audits of charts to audit completion of documents. Audit findings will be stored in a binder in Treatment Supervisor's office. This will begin in August 2022. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the dated signature of the witness.Client # 3 was admitted on December 30, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 30, 2021 to a government agency did not have a dated signature by the witness.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Consent form requirements will be reviewed in Unit Staff meeting on 8/2/2022. A minimum of 5 charts will continue to be reviewed monthly by Treatment Supervisor and Lead counselor will conduct weekly audits of charts to audit completion of documents. Audit findings will be stored in a binder in Treatment Supervisor's office. This will begin in August 2022. |