INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Chances 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) (6) 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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document on an informed and voluntary consent to release information form the date, event or condition from which the consent will expire in two of seven client records reviewed.
Client #1 was admitted on November 13, 2019 and was active at the time of inspection. There was a consent form to the funding source, signed and dated by the client; however, there was no date, event, or condition for when the form would expire.
Client #2 was admitted on November 11, 202 and was active at the time of inspection. There was a consent form to the funding source, signed and dated by the client; however, there was no date, event, or condition for when the form would expire.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
1. All staff will complete the PA DDAP: Drug and Alcohol Confidentiality training course online as a refresher, which covers Consent to Release of Information requirements, including end-dating.
Completed by July 31, 2021
2.
Program Director and TQM will include review of the expiration date, event or condition for all the release of information forms in quarterly reviews
Beginning July 2021
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