INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addiction Treatment 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) 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
The facility failed to obtain an informed and voluntary consent from the client in one of six client records reviewed on March 29, 2017.
Six client records were reviewed. In client record # 5 a fax was sent to the probation office. There was no release of information for the probation office documented in the record. Information was released to funder. There was no release of information documented for the funder.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be conducted by clinical supervisor during individual supervision regarding the necessity of valid releases for information to be released from the program, to include specifically probation and all funders. Agency policy and regulations for confidentiality will be also be reviewed at individual supervision, as will the disciplinary process for confidentiality violations. The clinical supervisor will conduct ongoing chart monitors to ensure that releases of information are being completed for all funding sources and probation, as well as any other information being released from the record. |
709.30 (1) 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.
(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.
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Observations
The facility failed to document written acknowledgement that the clients were notified that: No client may be deprived of a civil rights solely by reason of treatment; Reasons for removing sections of the client's record shall be documented in the record and that the client has the right to appeal a decision limiting access to their records to the director, in six of six records reviewed on March 29, 2017.
Six records were reviewed. Client records # 1, 2, 3, 4, 5 and 6 did not document that the client was informed of the above rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Changes were made to the Patient Rights section of the agency handbook to reflect this deficiency. A statement will be added stating: No client may be deprived of civil rights solely by reason of treatment. The following statements will be added to the section addressing clients' access to their records: Reasons for removing sections of your record will be documented in your record, and you have the right to appeal a decision limiting your access to your record to the program director.
Patient rights will continue to be reviewed at the intake appointment. An additional section will be added to the acknowledgement page of the intake document requiring the client's initials that the client rights have been reviewed.
These changes will be implemented by the clinical supervisor and reviewed with staff by the clinical supervisor to be completed by April 17th, 2017. The clinical supervisor will provide ongoing chart monitors to ensure that these changes are occurring.
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