INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 19, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Empowerment Resurrection Center 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
One client record was reviewed on April 19, 2017. It was observed in one of one records that the facility released patient identifying information to a laboratory and failed to obtain an informed and voluntary consent or a QSOA prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In Reference to Client#1 "Facility released identifying information to a Laboratory and failed to obtain an informed and voluntary consent or a QSOA prior to the disclosure"
Facility Director & Counselor was retrained on 5/3/2017 on PA Code 255.5 as well as related section 709.28 of the policies and procedures manual, administrative policies, Titled: Confidentiality. Future staff will be trained to focus on consent form and staff confidentiality.
All Staff as well as the Board of Directors where refreshed on 709.28 which specifies keeping client records confidential. The Agencies consent form will be used for Quest Diagnostic for all future clients until we obtain a QSOA. In addition ERC will regularly review charts to ensure proper releases for information are being obtained.
ERC was in complete compliance and aware of the nature of the plan of Correction as of 5/4/2017
ERC is in the process of developing a QSOA to share with Quest Diagnostic until then, Client#1 was informed about the issue and has signed a "Authorization for the Release of Confidential and Protected Health Information" Form for his additional Quest Diagnostic visit.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
One client record was reviewed on April 19, 2017 for treatment and rehabilitation services.
Client #1 was admitted into treatment on January 11, 2017 and was still an active client at the time of the inspection. The facility was unable to provide documentation that the comprehensive treatment plan was developed with the client, as the plan had no date and no client signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
"The facility was unable to provide documentation that the comprehensive treatment plan was developed with the client, as the plan had no date and no client signature."
Facility Director & Counselor was retrained on Regulation 709.92 on 5/3/2017. Subject: Treatment and Rehabilitation Services. Staff Neglected to get a signature and date of his Primary Treatment Plan that was developed with the client. Staff was retrained in the components of an complete treatment plan as well as treatment plan updates.
Future staff will be trained in the importance of how to accurately complete a treatment plan in order provide the best services for our clients
Plan of correction was reviewed with The Board of Directors so we can learn from this oversight and to ensure that it does not reoccur. Regular Chart reviews will be conducted to ensure all components are addressed on a treatment plan, including date, time and all necessary signatures.
The Oversight was corrected on April 19, 2017. Client#1 file has been updated.
ERC was in full compliance as of 5/3/2017
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