INITIAL COMMENTS
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This is a result of an on-site complaint investigation conducted on March 23-24, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Habit OPCO, Inc. as found to not 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
Based on the review of patient records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information.
A patient was admitted on October 3, 2019 and discharged on August 4, 2021. A letter was sent to a government agency on March 25, 2020; however, there was no consent to release information form signed by client prior to disclosure of information.
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Plan of Correction
Dunmore CTC Clinic Director, Office Manager, and Clinical Supervisor will ensure that each patient signs all voluntary releases of information prior to disclosure of information to external agencies. Both clinical and Administrative personnel will review any and all new admissions and/or newly completed ROI's to ensure accuracy and compliance ? at minimum, on a monthly basis as part of the internal chart review process. Dunmore CTC staff will ensure that releases are present within the patient chart prior to releasing any information, externally. This information will be presented during the May 27th, 2022 all staff meeting to ensure compliance to this regulation. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of patient records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information.
Patient was admitted on October 3, 2019 and discharged on August 4, 2021. A release of information form dated November 5, 2019 to a government agency allowed for the release of dose history.
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Plan of Correction
Dunmore CTC Clinic Director and Clinical Supervisor are responsible for ensuring compliance with confidentiality and the limits established by 4 Pa. Code 255.5. Clinical Supervisor will continue to monitor for adherence to this regulation, on a monthly basis, as part of the internal chart review process. A review of the requirements for release of information and confidentiality documentation will be discussed during the monthly all staff meeting on May 27th, 2022. |