INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21-22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Outside-In School of Experiential Education, 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 May 15, 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 the client records on April 22, 2008, the facility failed to obtain a release of information form prior to the disclosure of information. Client record #2 included the documentation of two family treatment sessions, but the facility failed to obtain a consent to release information from the minor client for the family members who were participating in those group activities.
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Plan of Correction
Clinical supervisor will review expectations and regulations related to confidentiality during weekly program meetings. Clarification and education will be provided to the team regarding these expectations and opportunities provided for questions and answers regarding an areas of uncertainty. Clinical supervisor will support all clinical staff in attending PA Department of Health approved confidentiality trainings. Clinical supervisor will also review confidentiality issues and concerns during weekly individual supervision sessions to explore issues specific to each clinician's caseload. |