INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 14, 2010 through January 15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation Inc. 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 and a plan of correction is due on February 17, 2010.
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Plan of Correction
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709.29(a) & (b) LICENSURE Retention of Client Records
709.29. Retention of client records.
(a) Client records, whether original, reproductions or microfilm, shall be kept on file for a minimum of 4 years following the discharge of a client.
(b) If the project discontinues operation, it shall make known to the Department where its records are stored.
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Observations
Based on review of the policy and procedure manual the facility failed to have in place a policy that informed the Department where the records would be stored if the project discontinued operations.
The findings include:
The policy and procedure manual was reviewed on January 11 and 12, 2010. The facility failed to have a policy in place to inform the Department where they would store their records if the project discontinued its operations.
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Plan of Correction
Aldie's Quality Assurance Officer was made aware at the time of this licensing visit that the retention of records policy failed to identify how the agency would inform the Department where the records would be stored if the project discontinued operations. The Quality Assurance Officer wrote this item into policy at the time of the ispection at which time it was approved |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on overheard conversation and staff interview during the facility licensure inspection the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
On January 14, 2010 actual conversations between a counselor and client were overheard by the licensing specialists. The licensing specialist were located in a conference room that had counseling offices on either side. Counseling sessions were overheard from both offices during various times throughout the licensing visit. This was also verified by the facility director at 11:40 a.m. on January 14, 2010.
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Plan of Correction
Aldie Quality Assurance Officer/Site Director advised the licensing specialists on the day of review that issues with confidentiality were evident at the time that the site opened. Extra insulation was then added by the contractors which did not completely address the issue. The Licensing Specialists were advised that white noise machines were on order for all clinical offices. On 1/27/2010 these machines were received and distributed to staff. Staff have been advised to maintain use of these machines daily to ensure confidentiality . Site Coordinators will maintain weekly quality assurance monitoring of offices to ensure that this is being maintained. |