INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection regarding the plan of correction to the complaint investigation conducted on October 3, 2008 and as a follow up to the Show Cause Order issued on February 3, 2009. The follow-up inspection was conducted on May 7, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site follow-up inspection, Samara House of CYWA 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 investigation and a plan of correction is due on June 23, 2009.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of five client records on May 7, 2009, the facility failed to obtain an informed and voluntary consent to release information.
Findings were:
Client record #1 contained two consent to release information forms that lacked the clients name and the clients signature, yet information was released to the other treatment center listed on one form and information was provided to the government funding source listed on the other for. The facility released information to a probation office other than the one that they had a signed consent to release information to. The client never completed or signed a consent to release information to the probation office that the information was released to. the information released to probation exceeded 255.5 as it included information regarding drug paraphernalia found in the client's room and items used to cook the drug in the client's room.
Client record #2 contained two consent to release information forms that had the box "other" checked but lacked any documentation of what the other information was. One consent form was to a laboratory and one was to another treatment center.
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Plan of Correction
709.28 (c) Confidentiality
The project shall obtain an informed and voluntary consent for the disclosure of information contained in the client record.
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All staff will again be trained by the Director on June 15 on Confidentiality and given a copy of the PA Health Department State Regulations as it pertains to confidentiality and release of information (voluntary). CQI and Director will check weekly to ensure all consents are entirely completed and within the regulations of information released. To begin June 15, 2009. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of five client records on May 7, 2009, the facility failed to document that follow-up information had been completed for discharged clients.
Findings were: Five client records were reviewed on May 7, 2009. One of five records required that a follow-up be conducted.
Client #3 was discharged from the treatment facility on 4/6/09. Per facility policy a follow-up was to be conducted within seven days of the clients's discharge. No follow-up had been documented as of the 5/7/2009 inspection.
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Plan of Correction
709.53 Client records.
(a)(11) Follow-up information.
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Director will re-assign staff to follow-up on clients discharged within 7 days of client discharge. Training will include documentation and policy for follow-up. Copy of State Regulations will be given as of June 15, 2009. CQI Coordinator will check Aftercare Log to ensure follow-up is made and documentation will be checked bi-weekly. |