INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 30, 2021 through August 31, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Montco Recovery Center LLC 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) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of a witness on all release of information forms in eleven of eleven client records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/2/21, all release forms have been updated through electronic record system (KIPU) to require a therapist signature as well as a check box that the client was given a copy of the release form. |
709.83(a)(11) LICENSURE Client records
709.83. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in one of two applicable client records reviewed.Client #11 was admitted on May 26, 2021 and discharged on July 19, 2021. There was no documentation of follow-up information in the client record at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 9/2/21, all clients that have been discharged are being tracked on a discharge spreadsheet denoting dates of follow up at intervals of 30 days, 90 days, and 6 months. This spreadsheet will have alerts so that every time an interval is approaching, the therapist is notified as well as the Clinical Director so the follow up call can be made. |