INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28-29, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Arc Manor 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) 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.
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Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the release of information in one of twelve records. Client # 3 was admitted May 3, 2021, and discharged September 30, 2021. Information was faxed to a government agency on October 11, 2021, without written consent from the client.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has reviewed with senior management staff (Clinical Director, CFO, and lead supervisors) regarding the requirement to have a signed release on file before sending any information to an external agency. This will be reviewed in clinical staff meeting on 4/7/22 by the Clinical Director and with the administrative assistant staff meeting on 4/14/22 by the CFO. The supervisors will monitor any disclosure and releases on monthly file reviews. The administrative assistants will also double check for a valid release before sending out any information. |
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 a review of client records, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when disclosing specific information to a government agency in one of twelve records.Client # 10 was admitted September 22, 2021, and discharged October 13, 2021. The following information was faxed to a government agency: discharge summary, aftercare plan, psychiatric evaluation, histories, psychosocial evaluation, treatment plans, and medications.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director reviewed with both Clinical Director and CFO (who supervises the administrative assistants who manage record requests), discussing the regulations of confidentiality and the limits of confidentially to governmental agencies. The CFO will review these requirements with the medical records staff on 4/14/22. The CFO and Clinical Director will review record requests to ensure these are following regulations. The administrative assistants will also review these medical record requests before sending to ensure these are meeting regulations and the limits of confidentiality. |