INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care Center 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 obtain an informed and voluntary consent from the client prior to the disclosure of information in two of seven client records reviewed on June 7, 2017.Client # 6 was admitted on October 4, 2016. The consent to release information for the funding entity was signed on December 16, 2016. The facility director confirmed the facility disclosed the client's name and identifying information during the billing of counseling services provided. Client # 7 was admitted on September 27, 2016. The consent to release information for the funding entity was signed on November 7, 2016. The facility director confirmed the facility disclosed the client's name and identifying information during the billing of counseling services provided. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will obtain appropriate Consents to Release Information for clients #6 and #7 where obtaining the consents are possible and remains relevant. The Clinical Supervisors will develop and provide a training update of the accurate and appropriate completion of consents to release information by July 1, 2017. Information to be covered will include appropriate type of release, the appropriate release for funding sources, appropriate choice of information to be released; and limitations of 4 Pa. code subsection 255.5, at a minimum. This will be completed by July 1, 2017. Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and supervision. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to document that the treatment and rehabilitation plans were reviewed and updated at least every 60 days in two of six client records reviewed on June 7, 2017. Client # 4 treatment plan update was due on October 5, 2016. The update was completed November 10, 2016. Client # 6 treatment plan update due by April 28, 2017 was not documented. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review treatment plan timelines and regulations. Each staff member will be provided with a copy of our agency's policy and regulations in regard to treatment plan timelines. The supervisor will stress that treatment plan updates will be completed every 60 days as per regulation. This will be completed by July 1, 2017. To assure staff members are improving in this area internal chart audits will be conducted. The Clinical Supervisor will be responsible for this plan of correction and ongoing monitoring of same. |