INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 18, 2017, 2017 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 to be not 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
Seven client records were reviewed on August 18, 2017. The facility failed to document a valid consent to release information form in client records, #1-7. A U.S. Department of Justice consent form was being utilized by the facility for billing and communication purposes; however the facility did not obtain a facility consent to release. The consent used by the facility also allowed for the release of the client's treatment plan, substance abuse assessment, mental health assessment, treatment plans, and discharge summary which exceeds what is permitted to be released by 4 Pa. code 255.5.
Client #1 was admitted on 3/17/17 and was an active client at the time of the licensing inspection.
Client #2 was admitted on 3/24/17 and was an active client at the time of the licensing inspection.
Client #3 was admitted on 2/3/17 and was an active client at the time of the licensing inspection
Client #4 was admitted on 1/6/17 and was discharged on 5/23/17.
Client #5 was admitted on 11/18/16 and was discharged on 5/1/17.
Client #6 was admitted on 9/15/16 and was discharged on 5/16/17
Client #7 was admitted on 12/16/16 and was discharged on 4/25/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Executive Director of Women's Institute for Family Health will develop Disclosure forms bearing the name of Women's Institute for Family Health to obtain client consent to only release information as is permitted by 4 Pa. Code 255.5. The form will be developed and utilized by 10/12/2017.
The Executive Director will train agency staff on the utilization of the Disclosure form.
The Executive Director will review client records weekly to assure that the Disclosure form is being utilized. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Seven client records were reviewed on August 18, 2017. The facility failed to update the treatment plan every 60 days in client records, #2, 3 & 7.
Client #2 was admitted on 3/24/17 and was an active client at the time of the licensing inspection. A comprehensive treatment plan was created on 4/26/17; a treatment plan update was due by 6/26/17 but was not documented until 7/5/17.
Client #3 was admitted on 2/3/17 and was an active client at the time of the licensing inspection. A comprehensive treatment plan was created on 3/1/17; a treatment plan update was due by 5/1/17 but was not documented until 5/4/17.
Client #7 was admitted on 12/16/16 and was discharged on 4/25/17. A treatment plan update was created on 2/14/17; a treatment plan update was due by 4/14/17 but was not documented at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Executive Director of Women's Institute for Family Health will develop a system to generate reminder notices to counseling staff to assure that updates are completed within the 60 day time frame.
The Executive Director will review client charts weekly to assure that 60 day updates are completed within the 60 day time frame. |