INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 4, 2007 through December 7, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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 and a plan of correction is due on January 4, 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 a review of client records and staff interview, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to the funding source in two of two client records reviewed, #1 and 2. The facility had a consent form from the funding source allowing the funding source to obtain information, but the facility did not have a consent form to release information to the funding source.
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Plan of Correction
Release forms are completed for all clients. We believed the Magellan release form that is signed by all clients referred by this agency met this standard. The executive director will have clients sign an additional form on agency letterhead giving permission to release information to the insurance agency. The executive director will ensure, supervise and train staff to have this form completed for all Magellan referred clients by 1/15/08. |
709.83(a)(6) LICENSURE Client records
709.83. 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:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document aftercare goals with specific time frames in one of one client record reviewed, #5. Time frames for the aftercare goals indicated "ongoing" and were not specific for the client. Support services were also missing.
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Plan of Correction
Continuing care plans included goals that did not state specific time frames, but rather stated an open-ended time frame. Counselors were stating in reports that clients were to maintain sobriety and without a specific end date. Support services need to be reported more consistently on clients' records. The executive director will ensure, supervise and train staff to complete continuing care plans that include specific time frames, support services and resources. The program will be in full compliance by 2/4/08. |