INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Chester County Intermediate Unit - Changes, 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 a review of 14 client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) in 1 client record.
Client #3 was admitted on 1/12/17 and was discharged on 5/8/17. A consent to release form was signed and dated on 1/12/17 to a county probation officer and allowed for the release of the client's lab results, health records and psychological testing results.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 12/12/17 all clinical staff were re trained on consents to ensure that appropriate consents were executed moving forward.
Clinical Supervisor will ensure training of any new clinical staff moving forward.
New electronic record management will eliminate the opportunity for occurrence as the release completed will be 255.5 specific |