INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 20, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 18, 2007.
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The written procedures for the confidentiality of client identity and records contained a document designed by CODAPP titled "Confidentiality Regulations and the Drug and Alcohol Treatment Programs." This document contained various discrepancies regarding disclosure to the parents of a minor without the client's consent, and the wording "with or without the client's consent" to Judges and Probation/Parole. In addition, written procedures state that "a client may revoke a consent to release information, in writing, to the clinic or project manager. The facility must honor a client's verbal revocation and then document that verbal revocation.
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Plan of Correction
The Director of Quality Improvement has removed the CODAPP document from the policy and procedure manual. This was replaced with copies of the 255.5 and 42CFR regulations. The Project Director will oversee that the company's confidentiality policy is revised to allow for verbal revocation of consents. The Facility Director will oversee the distribution and review of this revised policy to all staff in staff meeting. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The specific information disclosed to the funding source exceeded the limitations imposed at 4 Pa. Code, Subsection 255.5(b) in that the consent to release information form included the initial evaluation, psychiatric evaluation, medical history and discharge summary in 4 out of 4 client records reviewed.
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Plan of Correction
The Quality Improvement Department will oversee the revision of this pre-formatted release to match the limitations of 255.5. The Facility Director will oversee that all staff receive copies of the revised release and are reminded of the limitations of 255.5 in staff meeting. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
The personal histories were incomplete, failing to address family relations, significant events/problems growing up, legal issues, recreation interests and sexual history in 3 out of 4 client records reviewed, specifically # 1, 2 and 3. In addition, documentation failed to clarify one word responses from the client.
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Plan of Correction
The Facilty Director will oversee that all clinical staff receive training in staff meeting to educate the therapists on gathering more detailed information regarding family relations, significant events/problems growing up, legal issues, recreation interests and sexual history in each client's personal history. |
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 treatment plan updates failed to address the client's progress in the past 60 days as it relates to the treatment plan goals identified on the individual treatment plan in 2 out of 2 client records reviewed, specifically # 1 and 2.
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Plan of Correction
The Facility Director will oversee that all clinical staff receive training in staff meeting to educate staff on completing a thorough treatment plan update which addresses the client's progress in the past 60 days as it relates to the treatment plan goals identified on the individual treatment plan. |