INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alcohol and Drug Abuse Services, Inc. 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
Based on a review of the 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 one of the seven client records reviewed.
Client # 7 was admitted on January 19, 2021 and discharged on May 18, 2021. There was communication between staff and a medical provider documented in the record on January 19, 2021, however there was no release of information form documented in the record prior to the disclosure.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. On 8/25/21 at 3pm the clinical supervisor advised all outpatient counselors of the results of the review and importance of checking for consents before sending any letters. All outpatient counselors were advised to document that there is a consent on the letter they are signing. Staff were instructed to indicate that the consent was checked on all form letters.
2. On 8/26/21 the clerical supervisor instructed all clerical staff to verify there is a consent before any letters are sent out.
3. On 8/27/21 the clinical supervisor and clinical staff in facility 537-034 reviewed every active client file to ensure all correspondence had a corresponding consent. They did.
4. Effective 8/27/21 during routine monthly chart reviews the clinical supervisor and outpatient counselors will ensure all correspondence has a corresponding consent.
5. The chart reviews from the previous month will be discussed at monthly outpatient department meetings (outpatient counselors, clinical supervisor). These occur the 1st Thursday of each month. Any discrepancies will be addressed immediately.
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709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the 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 including date, event, or condition upon which the consent with expire in one of the seven client records reviewed.
Client #6 was admitted on February 16, 2021 and discharge on Ma6 6, 2021. A release of information for the funding source contained in the client record did not have an expiration date included on the consent.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
1. As of 8/25/21 at 3pm the clinical supervisor reviewed the findings with all outpatient counselors. All counselors were retrained on how to fill out a consent properly and to be sure there is an expiration date. The clinical supervisor sent a follow up email indicating importance of completing a consent correctly on 8/25/21.
2. On 8/27/21 the clinical supervisor and clinical staff in facility 537-034 reviewed every active client file to ensure consents were completed correctly. They all were.
3. Beginning 8/27/21 during routine monthly chart reviews the clinical supervisor and outpatient counselors will review consents to ensure they are completed correctly.
4. The chart reviews from the previous month will be discussed at monthly outpatient department meetings (outpatient counselors, clinical supervisor). These occur the 1st Thursday of each month. Any discrepancies will be addressed immediately.
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