INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 7, 2017 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, Family Service & Children's Aid Society 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 from the client prior to disclosure in one of seven client records reviewed on November 7, 2017.Client #6 was admitted to treatment on August 29, 2017. 1.)The facility failed to document a release of information for the funding source. 2.)A release of information for a physician was signed on 8-29-2017, but failed to indicate the specific information to be disclosed and the purpose for the disclosure.3.)A release if information for an emergency contact was signed on 8-29-2017. The expiration date indicated the release of information expired on 8-29-2017.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor met with all clinical staff from the Oil City, Titusville and Franklin offices on November 6,2017 at our bi-monthly staff meeting. It was discussed for the individual counselors to ensure all proper boxes on the release of information forms are checked. The releases of information forms will also be checked during the initial intake chart checks and any other subsequent chart During the chart checks by staff they will ensure the boxes are checked and when warranted the box for insurance processing. It will be discussed with the clinical staff during their weekly supervision and randomly checked by the clinical supervisor and/or Program Director. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to include the reason for involuntary termination in the written notice given to clients in two of two client records reviewed on November 7, 2017. Patient # 2 - The discharge date was 10-23-2017. A termination letter was sent to the client, but did not include the reason for termination. Patient #3 - The discharge date was 10-10-2017. A termination letter was sent to the client, but did not include the reason for termination. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor met with the Clinical staff from the Oil City, Titusville and Franklin office on Monday, November 6th to discuss the changes needed for our termination letters. The termination letters are missing the reason for termination and the process for re-admission after termination.
Upon the completion of termination letters with the drop down box added each counselor will be given the templet for the revised termination letter which will include reasons for termination and the process for returning to treatment are explained. This letter will be saved on the H Drive at each office where all counselors will have access to it, and a hard copy will be distributed to each counselor to start using 12/1/17.
This process will be distributed and discussed at the 11/27/17 D&A staff meeting; a hard copy of the revised letter will be handed out and discussed with staff at that time also. When termination of a client is evident, a case consult will be completed between the counselor and the Clinical Supervisor and what the reason for termination will be discussed. Also, when the Clinical Supervisor completes the discharge chart check the termination letter will be reviewed again. These steps and the process will be reiterated during individual supervisory sessions clinical staff meetings.
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