INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 5, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia, Inc. Coatesville, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiency were identified during this inspection:
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Plan of Correction
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted June 5, 2017 it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
1.A group session could be overheard in the hallway outside the group room A.
2.A counseling session could be over heard in the hallway outside counselor office number 10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the finding on June 5, 2017, of failing to ensure privacy so that counseling sessions cannot be seen or heard, Gaudenzia Coatesville Outpatient will ensure that all white noise machines will be on outside the counseling rooms and counselor offices, all doors will be closed while treatment is in session to ensure privacy. Program Director, Clinical Supervisor, and/or Administrative Coordinator will check daily to make sure all white noise machines are on and working properly and will also monitor each office to make sure doors are closed to protect clients' privacy. Program will develop a daily checklist of these items and to be signed by person that conducting the monitoring. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of patient records, the facility failed to keep disclosures of patient identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in patient record # 2 .
Client # 2 was admitted to the outpatient drug-free activity on 2/1/17 and was an active patient at the time of inspection. An email dated 4/6/17 in the clients file was sent to a probation officer who did not have a signed consent to release information form from the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the finding on June 5, 2017 in which the facility failed to keep disclosures of patient identifying information, Gaudenzia Coatesville Outpatient, will ensure that all information being released to outside agencies, all information will coincide with release of information and will be monitored by clinical supervisor and program director. |