INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11 through 14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Teen Challenge Training Center 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 April 14, 2008.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed consent in seven of seven records reviewed, # 1, 2, 3, 4, 5, 6 and 7. A general release of information form was used for the release of medical billing information. The general release form did not include who the information was to be released to, if a copy was offered to the student, the expiration date of the consent and the specific information to be released.
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Plan of Correction
The Medical department will discontinue using the forms. The Medical Services Supervisor will make sure they are no longer used. If needed they will start using and complete in its entirety the "Release of Information Form" which has been approved by the state and used by the counseling department. Clinical Supervisor has communicated this already and assured that the for is discontinued. |
709.28(c)(3) 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. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in two of seven records reviewed, #1 and 3. Client record #1 contained two consent to release information forms where the purpose for both was to obtain benefits from the Department of Public Welfare. One release form was to the client's mother and one was the Teen Challenge Induction Center. The purpose of obtaining welfare benefits was incongruent with to whom the information was being released to. The purpose was missing on one consent form in client record # 3.
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Plan of Correction
The Clinical Supervisor has since provided training for the counselor's on how to fill out and explained the purposes any types of releases. He will insure that these are being filled out properly by reviewing a file from each counselor monthly to insure they are being done correctly and completely. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information in three of seven records reviewed, # 8, 10 and 12. Follow up information was missing.
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Plan of Correction
The Clinical Supervisor has since provided training for the counselor's on the purpose and how to fill out follow-up contact reports. The training included the time frame and what if's. He will insure that these are being filled out properly by reviewing a file from each counselor monthly to insure they are being done correctly and completely. |