INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 25, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Sojourner House 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.
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Observations
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed on April 25, 2017.
In client record # 2 information was disclosed to a third party payor. There was no consent to release the information documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will train counseling staff to collect third party payor information at the time of intake & throughout treatment should the third party biller change. Clinical Supervisor will train the counseling staff to complete the voluntary consent with the corresponding payor at the time of intake & throughout treatment as appropriate. Clinical Supervisor will follow up by completing a chart audit within the first 7 days of a residents admission to ensure completion and compliance. Clinical Supervisor will be responsible for the oversight of these processes. |