INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28 -29, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Familylinks, 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 and a plan of correction is due on August 25, 2008.
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Plan of Correction
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual on July 14, 2008 and July 16, 2008, the facility failed to provide consistent time frames for aftercare plans.
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Plan of Correction
Beginning September 1, 2008, the Facility Director will revise the Program's Policy and procedure Manual to ensure the policy reflects the proper periods for completion of the aftercare plan. The Facility Director will review the Policy and Procedure Manual monthly to ensure documentation complies with the policy. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a client record review on July 28, 2008, the facility failed to complete the purpose section of the consent to release information forms for Probation and another entity. Refer to client records #2 and 4.
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Plan of Correction
Beginning September 1, 2008, the Facility Director will conduct trainings on the accurate documentation of Releases of Information. The Facility Director will ensure through weekly supervisions that Releases of Information are fully completed. The Facility Director will review 10 charts monthly to ensure compliance.
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