INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 26 - 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso, Inc. 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 January 3, 2008.
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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 client records on 11-27-07, 11-28-07, 11-29-07 and 11-30-07, the facility failed to provide completed releases of information for clients. Client record # 5 and 14 are missing the expiration date. Client record #10 is missing a witness signature. Client record #17 is missing the specific information to be released and the purpose of the disclosure. Client records # 10 and 15 are missing the documentation if the client accepted/declined a copy of the release form.
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Plan of Correction
Consent forms for the release of information were not completed properly by a new staff member of the Fiscal Department. The individual will undergo in-house training by the supervisor of the unit to ensure that all facets of the regulations are implemented. Client files will be reviewed to obtain new releases of information that conform to standards. The new staff person will also be scheduled and sent to the 6 hour Confidentiality course offered by the Department of Health to provide further education and training. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
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Observations
Based on a review of the client records on 11-30-07, the facility failed to complete the discharge summary in accordance with agency policy. This occurred in three of five client records reviewed. Client records # 18 and 22 are 10 days late, and client record # 19 is six weeks late.
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Plan of Correction
The discharge summaries were not completed within the regulated time frame. This is a result of the giving the client a four day leeway to return to the clinic after the last date of medication. The discharge date is the last date of medication. All counselors will be instructed to use the last date of medication as the discharge date and to complete the discahrge summary with in seven days from that date. This instruction will be given by the Director of Social Services and files will be reviewed for compliance. |