INITIAL COMMENTS
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This report is a result of an on-site methadone monitoring and licensure renewal inspection conducted on Septmeber 21, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Choices, LLC 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 the review of client records, the facility failed to obtain an informed and voluntary consent from the client in one of ten records.
Client # 6 was admitted on May 22, 2020 and was still an active client at the time of the inspection. A release for the funder was signed by the client on May 22, 2020. The release expiration date was documented as one year from the date of signature. The consent expired on May 22, 2021. Information was released after this date to the funder.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide in-house training related to Funding Source releases including any and all insurance providers which may access patient information and their expiration dates to the Clinical Staff on October 28, 2021. Facility Director will document the training via issuance of training certificates to staff and will maintain documentation of the training on site for review. Clinical Supervisor will monitor on-going compliance through random chart audits to ensure compliance. |
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 client records, the facility failed to obtain an informed and voluntary consent that included the specific information disclosed in one of ten records.
Client record # 2 was admitted on June 21, 2021 and was still an active client at the time of the inspection. Two consents, signed by the client on June 21, 2021, did not document the specific information to be released.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will provide in-house training related to Specific Information which can be released via consent as well as consent completion to the Clinical Staff on October 28, 2021. Facility Director will document the training via issuance of training certificates to staff and will maintain documentation of the training on site for review. Clinical Supervisor will monitor on-going compliance through random chart audits to ensure compliance. |
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
Based on the review of client records, the facility failed to obtain an informed and voluntary consent that included the purpose in one of ten records.
Client record # 2 was admitted on June 21, 2021 and was still an active client at the time of the inspection. Two consents, signed by the client on June 21, 2021, did not document the purpose.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Clinical Supervisor will provide in-house training related to the Purpose of the release being completed on the form as well as overall completion of releases to the Clinical Staff on October 28, 2021. Facility Director will document the training via issuance of training certificates to staff and will maintain documentation of the training on site for review. Clinical Supervisor will monitor on-going compliance through random chart audits to ensure compliance. |