INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 1, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Service Foundation, 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
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client #6 was admitted on December 3, 2020 and was discharged on May 26, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to obtain written informed and voluntary consent to release information form for client #6 who was admitted on December 3, 2020 and discharged on May 26, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures. The clinical supervisor will ensure that client files will contain a consent to release information form for the funding source. This will be done through regular client file checks by the clinical supervisor. Training of all staff will be completed by 2/28/2022. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of a client on release of information forms in one of seven client records reviewed.
Client #7 was admitted on May 4, 2021 and was discharged on November 4, 2021. There was a release of information form to a funding source signed by the witness on May 11, 2021 in the record. However, there was no documentation of the dated signature of the client on the form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document the dated signature of a client on release of information forms on client #7 who was admitted on May 4, 2021 and discharged on November 4, 2021. The clinical supervisor will ensure that all releases are dated through regular client file checks. Staff will be trained and supervised by the clinical supervisor to ensure that dates are documented in the client's file. Training of all staff will be completed by 2/28/2022. |