INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 10, 12, 13, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service and Children's Aid Society 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 December 10, 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 on the review of client records, the facility failed to provide an informed consent to release information in one of five client records.
The findings include:
Five client records were reviewed on November 12 and 13, 2008. All five of the records were required to have consent to release information forms. Client record #4 included a release to the Venango County Substance Abuse Program that did not indicate the specific information to be disclosed or the purpose for the disclosure. Also in client record #4, the consent to release information forms to the clients grandmother and to Venango County Court Supervision did not include a purpose that was relevant to the release of information. Both of these consent to release information forms had all four reasons under the purpose indicated as the reason for the disclosure.
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Plan of Correction
A mandatory staff meeting has been scheduled for 3 PM on December 3, 2008. Both the drug & alcohol program director and the clinical supervisor will review this finding with the clinical staff. The chart check procedure will also be reviewed so as to ensure all consents are properly completed and signed, including the correct purpose of the disclosure being checked.
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