INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 17-19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers, 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 18, 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 upon a review of client records on March 19, 2008, the facility failed to ensure that consents to release information were informed and voluntary in eight of eight client records reviewed. Client records #1 through 8 contained consents to release information that did not allow for the verbal revocation of consents. The consent to release information forms stipulated that if the client wished to revoke the consent that they had to do so in writing.
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Plan of Correction
- All consent forms will be updated and distributed to staff by 4.15.08.
- Staff will be trained regarding verbal revocation of a consent form by 4.15.08 by Clinical Supervisor.
- Clinical Supervisor will continue to monitor on a weekly basis the completeness of consents.
- Staff will be supervised on an on-going basis regarding the importance of confidentiality and the accurate completion of consent forms to ensure that NET is in compliance with this regulation. |
709.93(a)(2) LICENSURE Client records
709.93. 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:
(2) Medication records.
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Observations
Based upon a review of client records on March 19, 2008, the facility failed to include the dosage and frequency of use of medications in two of four client records reviewed, #2 & 3.
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Plan of Correction
- Staff will be re-trained by 4.15.08 regarding the importance of completing the medication section of the Biopsychosocial history in its entirety, including steps to be taken if the client does not have the information needed, i.e. request that the client bring in the information, and then documenting such medication information in the BPS once obtained
- The BPS will be reviewed and audited by Clinical Supervisor on a weekly basis to ensure that NET is in compliance with this regulation. |