INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 24, 2012 licensure renewal inspection. The follow-up inspection was conducted on February 4, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Allied Addiction Recovery, 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.
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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 the review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of three client records.
The findings include:
Six client records were reviewed on February 4, 2013. Three client records were reviewed for compliance with obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. The facility did not document that an informed and voluntary consent from the client was obtained prior to the disclosure of information contained in the client record in client records # 1, 2 and 3.
Client # 1 was admitted on November 28, 2012. A fax containing client information was sent to a third party payer on December 5, 2012. There was no documentation of an informed and voluntary consent signed by the client for the release of this information to the third party payer.
Client # 2 was admitted on October 31, 2012. A fax containing client information was sent to a third party payer on November 5, 2012. There was no documentation of an informed and voluntary consent signed by the client for the release of this information to the third party payer.
Client # 3 was admitted on October 31, 2012. A fax containing client information was sent to a third party payer on October 31, 2012. There was no documentation of an informed and voluntary consent signed by the client for the release of this information to the third party payer.
The Facility Director was interviewed on February 4, 2013 and confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on the review of client records, the facility failed to document case consultation notes that listed all of the participants of the case consultations in two of two client records.
The findings include:
Six client records were reviewed on February 4, 2013. Two client records required documentation of case consultation notes. The facility did not document case consultation that listed all of the participants of the case consultations in client records # 1 and 2.
Client # 1 was admitted on November 28, 2012. A case consultation note was completed on January 26, 2013. The case consultation note documented only the signature of the person completing the note. There was no documentation of staff member participation.
Client # 2 was admitted on October 31, 2012. A case consultation note was completed on December 28, 2012. The case consultation note documented only the signature of the person completing the note. There was no documentation of staff member participation.
The Facility Director was interviewed on February 4, 2013 and confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |