INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18, 2007 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 May 18, 2007.
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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 shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The written procedures for the confidentiality of client identity and records contained a document designed by CODAAP titled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs." This document contained incorrect language regarding disclosure to parents of a minor without the client's consent and wording "with or without the client's consent" to judges and probation/parole. In addition, written procedures stated that "a client may revoke a consent to release information, in writing, to the clinic or project manager. The facility must honor a client's verbal revocation of a consent and the facility must document the verbal revocation in writing.
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Plan of Correction
The Director of Quality Improvement has removed the CODAPP document from the policy and procedure manual. This was replaced with copies of the 255.5 and 42CFR regulations. The Project Director will oversee that the company's confidentiality policy is revised to allow for verbal revocation of consents. The Facility Director will oversee the distribution and review of this revised policy to all staff in staff meeting. |
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
Consent to release information forms stated that clients must revoke their consent in writing in ten of ten records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. Clients may verbally revoke a consent and the facility staff may put this revocation in writing.
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Plan of Correction
The Quality Improvement Department is currently overseeing the revision of our consent forms to allow for written or verbal revocation. The Facility Director will oversee that all staff receive the revised consent forms and are educated on how to document verbal revocation. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal histories failed to address family relations, significant events/problems related to the family history and recreation interests in ten of ten client records reviewed, specifically # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. In addition, one word answers were indicated without any additional clarification by the clinician.
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Plan of Correction
The Facility Director will oversee that all clinical staff receive training in staff meeting to educate the therapists on gathering more detailed information regarding family relations, significant events/problems related to the family history and recreation history in each client's personal history. Therapists will also be reminded to avoid one word answers and to clarify responses from the clients. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
The aftercare plans failed to include realistic and measurable goals and support services in three of three client records reviewed, #7, 8 and 10.
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Plan of Correction
The aftercare plan has been revised to prompt therapists to give more realistic and measurable goals and support services. The Facility Director will oversee the distribution and review of the revised aftercare plan to all clinical staff in staff meeting, highlighting the importance of creating realistic/measurable goals and support services. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Follow up information was not documented in two of two records reviewed, #6 and 9.
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Plan of Correction
The Facility Director will oversee that follow-up information is sent and documented in each client chart. |