INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21, 2006 through September 22, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on October 24, 2006.
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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
There were three counseling offices located in the basement which had clear vision panels in the doors that were not covered.
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Plan of Correction
The clear vision panels in the doors will be covered with creative paper by October 31, 2006. |
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 shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The HIPAA notice stated that while a client had the right to restrict information to be released, Gaudenzia did not have to agree to those restrictions in 10 of 21 client records reviewed, # 1-10. This language incorrectly implies that Gaudenzia would be able to release information without the client's informed and voluntary consent.
Consent to release information forms exceeded that allowed by 4 Pa. Code 255.5. The consent forms authorized the release of psychosocial evaluations and/or aftercare plans to third party payers, parole officers, and/or pre-trial services in three of 21 client records reviewed, #6, 17 and 20.
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Plan of Correction
Revisions to the HIPPA notice were changed and approved in 2004 by the Division of Licensing. These forms will be utilized by this facility immediately.(10/24/06) Program Supervisor is responsible for training staff and disposing of the inaccurate forms.
The Program Supervisor is responsible for training the counselors responsible for the information which exceeded the 4 PA. Code 255.5. This will be completed by October 27, 2006.
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