INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Women's Institute For Family Health 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 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility obtained signed informed consents to release to the federal prison system the treatment plans for 3 clients, and the facility released the treatment plans of these clients to the federal prison system, but releasing the treatment plans of the clients to the federal prison system violates 4 Pa. Code 255.5.
Client #1 was admitted for treatment on 2/17/2016, and discharged from treatment on 6/01/2016. The client's treatment plan was released to the federal prison system.
Client #2 was admitted for treatment on 1/15/2016, and discharged from treatment on 6/23/2016. The client's treatment plan was released to the federal prison system.
Client #3 was admitted for treatment on 1/08/2016, and discharged from treatment on 6/13/2016. The client's treatment plan was released to the federal prison system.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
The Project Director will assure that Women's Institute for Family Health will not release treatment plans to the Federal Bureau of Prisons or any other federal agency. All staff will be required to sign a statement acknowledging that releasing treatment plans to government agencies is against Women's Institute for Family Health policy,and in signing this statement staff are agreeing to abide by this policy and acknowledge understanding that failure to adhere to this policy will result in immediate termination. This policy will go into effect immediately |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The individualized treatment plans do not document the frequency of counseling services provided in 3 client records reviewed.
Client #1's individualized treatment plan was completed on 3/16/2016, but the treatment plan does not document the frequency of counseling services to be provided.
Client #3's individualized treatment plan was completed on 2/08/2016, but the treatment plan does not document the frequency of counseling services to be provided.
Client #7's individualized treatment plan was completed on 3/08/2016, but the treatment plan does not document the frequency of counseling services to be provided.
These findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
The Project Director of Women's Institute for Family Health will assure that the frequency of counseling services provided to clients will be entered in client records. This will be accomplished by adding a section on comprehensive treatment plan forms for this information to be entered. The Project Director will inspect client records on a monthly basis to assure that this information is being recorded by Counseling staff. The form will be completed by 9/15/16 |
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
The facility completed discharge summaries in 4 client records prior to the clients being discharged from treatment.
Client #2's discharge summary was dated 6/09/2016, but the client's last counseling session was dated 6/23/2016.
Client #3's discharge summary was dated 6/09/2016, but the client's last counseling session was dated 6/13/2016.
Client #4's discharge summary was dated 11/25/2016, but the client's last counseling session dated was 12/31/2016.
Client #5's discharge summary was dated 1/06/2016, but the client's last counseling session was dated 1/20/2016.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The Project Director will assure that client discharge summaries will be completed on the last day of treatment. All staff will be required to sign a statement acknowledging receipt and understanding this policy. The Project Director will review all discharge summaries on a monthly basis to assure that forms are being completed on the last date of treatment. |