INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling and Psychiatric Services 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 April 14, 2008.
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policies and procedures, the facility failed to have a written procedure that complied with 4 Pa. Code 255.5. The facility's written procedures for the confidentiality of client identity and records contained a document entitled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs". This procedure included the wording that allowed for the release of client information "with or without the client's consent" to judges and probation/parole.
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Plan of Correction
The Director of Quality Improvement has revised the "Confidentiality Regulations and the Drug and Alcohol Treatment Programs" procedure to state that client information can only be released with the client's consent to judges and probation/parole. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in two of six records reviewed, #1 and 5. Information was released to Dauphin County Probation without a signed consent to release information form in client record #1. Information was released to the client's employer without a signed consent to release information form in client record #5.
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Plan of Correction
The Facility Director will oversee that staff are educated through staff meeting of the importance in obtaining an informed and voluntary consent prior to releasing client information. The Quality Improvement Department and office administration will provide ongoing monitoring through chart audits to ensure compliance. |