INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 26, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie, Inc./Daniel Snow House was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
|
Plan of Correction
|
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.
|
Observations
Six client records were reviewed on October 26, 2017. The facility failed to document a valid consent to release information form in client record #6. The consent template used in record #6 stated the consent could only be revoked by notifying the program director.
A consent to release to a government agency dated March 15, 2017.
A consent to a funding source, dated January 10, 2017.
A consent to a government agency, dated January 10, 2017.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Program Director will meet with all Staff and review the release of information that is to be used with all clients. Program Director will review this with the staff by 12/01/2017.
Program Director will check the company folder and facility files to ensure all incorrect/outdated blank consents are disposed of so that the wrong forms are not used moving forward. program Director will complete this facility check by 12/01/2017.
Program Director will complete monthly chart audits in November 2017 to ensure correct consents of release are being used. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in six of six client records reviewed on October 26, 2017.
There was no documentation that the client was informed that the project, facility or clinical director would document the reason for removal from the client's record of any material deemed detrimental to the client in client records # 1-6.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Division Director will review and adjust agency policy as needed to ensure all required client rights are listed in rights that are reviewed with clients upon admission. Division Director will complete this review by 11/14/2017.
Division Director will review agency policy/client rights with the Program Director by 11/17/2017.
Program Director will review updated policy/client rights with all staff by 11/21/2017.
Staff will begin using updated policy/client rights with all clients starting 11/22/2017.
|