INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 March 1, 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, Montco Recovery Center LLC. 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:
|
Plan of Correction
|
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of ten client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two client records.
Client #2 was admitted don February 28, 2020 and was still active at the time of the inspection. A consent to release form was signed and dated on February 28, 2020 for probation officer which allowed for the release of discharge summary and assessments.
Client #5 was admitted on August 13, 2020 and was discharged on December 3, 2020. A consent to release form was signed and dated on August 13, 2020 for probation office which allowed for the release of treatment plan and summary.
These findings were discussed with facility staff during the inspection process.
|
Plan of Correction
Clinical Director has created a new release titled Legal Entity and only Presence in treatment, Progress in treatment, Nature of Project, Prognosis, and Relapse Status and Frequency are options. All clients that previously had a release on file with additional information to release has been corrected. |