INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, DARS, Inc. Supervised Independent Living Program 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 September 29, 2008.
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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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on an August 27, 2008 review of six clients records, the facility failed to properly document the specific purpose of disclosure on the consent to release information form for three of three client records where required.
Finding:
The consent to release information form contained generalized and uniform information for the purpose of disclosure, rather than the specific information that would be disclosed in client records # 1, 2 and 3.
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Plan of Correction
The DARS, Inc. SIL Program Director and Assistant Program Director revised the confidentiality form to address the specific purpose of disclosure of client information. This form was reviewed with the Counselor Assistant by the Program Director and Assistant Program Director to ensure that the reason for confidentiality is specifically addressed and confidentiality is upheld to meet the regulations. This form was implemented as of 8/28/2008. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of six clients records on August 27, 2008, three were required to have an individual treatment and rehabilitation plan. The facility failed to document the type and frequency of treatment and rehabilitation services in two of three client records where required.
Finding:
Documentation of the type and frequency of treatment and rehabilitation services was missing from client records #2 and 3.
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Plan of Correction
The type/frequency of services form(form #38) will be attached to the Master Treatment Plan upon its development. Signature lines were added to form #38 for the Program Director/Assistant Program Director to ensure the supervision of this plan of correction is completed to meet requirements and outline the type and frequency of services outlined in the Master Treatment Plan that the client will receive. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of six client records on August 27, 2008, the facility failed to document the reason for treatment on the discharge summary in four of four client records where required. four were required to have a discharge summary.
Finding:
Documentation of the reasons for treatment was missing from the discharge summaries in client records #3, 4, 5, and 6.
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Plan of Correction
On August 28, 2008, the Program Director and Assistant Program Director consulted with the Counselor Assistant regarding the content of Termination/Discharge Summaries. It was the concensus of the staff to implement the client's treatment reason for entering the SIL Program in the first paragraph of the Termination/Discharge Summary. This change will include previous placement(s), date of entry into SIL and the need for SIL Program treatment services. |