INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 8, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program Central, 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:
|
Plan of Correction
|
711.93(c)(2)(iv) LICENSURE Signature Client/Guardian
711.93. Client records.
(c) Confidentiality.
(2) 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:
(iv) The dated signature of the client or guardian.
|
Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in seven of seven client records reviewed. Every release of information form in each client record reviewed failed to document the dated signature of the client. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Due to the ongoing public health crisis, the therapeutic staff were instructed to forego in-person sessions for the purpose of social distancing. As such, ROI forms lacked patient signatures but were verbally acknowledged. In response to the inspection, the therapeutic staff have been informed that all ROI forms and consents must bear the client signature. Review of charts by Facility Director will ensure compliance with the standard. |