INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, TrueNorth Wellness Services 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) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of seven client records, the facility failed to document a completed consent to release information in three records, as there were forms that were missing required information.
Client#5 was admitted on December 31, 2018 and was discharged on April 22, 2019. There was a consent to release form, signed and dated on November 27, 2018 to DUI programs , but the consent form did not include the specific information disclosed.
Client#6 was admitted on December 26, 2018 and was discharged on June 10, 2019. There was a consent to release form, signed and dated on October 11, 2018 to DUI programs , but the consent form did not include the specific information disclosed.
Client#7 was admitted on February 14, 2019 and was discharged on June 25, 2019. There was a consent to release form, signed and dated on January 22, 2019 to DUI programs, but the consent form did not include the specific information disclosed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CRN Evaluator was instructed by the Director of Substance Abuse Services to include what information she is releasing, i.e. the CRN document, in the Release of Information as the release becomes part of the client record and needs specific information. Corrected 8/15/19. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in client record # ' s 1, 2, 3, 4, 5, 6, and 7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Client Bill of Rights form was updated by the Clinical Supervisor to include all required items under the regulation in the Welcome Packet given to all D&A clients. New packets were printed and older versions were destroyed on 8/15/19. |