INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Gaudenzia Erie Inc. - Girard Satellite Office 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 document an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed on October 18, 2018.
Client # 7 was admitted February 2, 2018 and discharged May 2, 2018. The client's name and a progress report were released to the probation office.
The findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the 2017 licensing inspection.
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Plan of Correction
Program Director will review all policies and regulations related to confidentiality. Clinicians will obtain written informed consent for all clients for all necessary parties. Files will be reviewed monthly to ensure compliance. Finding from monthly chart reviews will be discussed in monthly quality improvement meetings. |