INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 3, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Gate House Mountville 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) (3) 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:
(3) Purpose of disclosure.
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Observations
The project failed to ensure that the purpose of disclosure was included on an informed and voluntary consent to release information form in one of seven client records reviewed.Client #7 was admitted on July 11, 2019 and was discharged on October 11, 2019. A consent to release information form to another treatment provider, signed by the client on July 31, 2019, did not document the purpose of the disclosure.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
In an effort to address citation 709.28 the following will be implemented:
Beginning 10/01/2020, all staff completing confidentiality forms will ensure that it is completed in its entirety. Specifically, the staff will ensure that the purpose of the disclosure is documented.
The Clinical Director will monitor the progress of this correction during the monthly chart reviews. |