INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on August 6, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Cen-Clear Child Services Inc. 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
The facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of seven client records reviewed on August 6, 2020.
Client # 5 was admitted on February 20, 2020 and discharged on April 26, 2020. The release of the client's name and diagnosis to the funding entity occurred on February 20, 2020.
Client # 7 was admitted on March 12, 2020. The release of the client's name and diagnosis to the funding entity occurred on June 9, 2020.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 5 - 6, 2019 licensing inspection.
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Plan of Correction
Facility Director has corrected this deficiency by requiring all consumers to complete a consent for the county funding and the insurance company that is affiliated with the county in which they reside.
Drug and Alcohol Navigators were instructed immediately following licensing that consumers that were opened prior to licensing (and not discharged) needed to complete these consents as well. Quality Assurance will conduct random chart audits to ensure consents for the funding entity are documented.
Facility Director will ensure these consents are obtained during the initial session with the consumer for further monitoring.
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