INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 27, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Hope Springs Behavioral 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 (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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client #3 was admitted on September 9, 2018 and was still active at the time of the inspection. There was documentation that the funding source was contacted during the client's treatment episode; however, there was no consent to release information documented in the record prior to the disclosures.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility director will ensure all informed and voluntary consents are obtained on the day of the client's intake. The facility director will check client records on a monthly basis to ensure the informed and voluntary consents are obtained and are in full compliance of state regulations. |