INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Erie Inc./Community House 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 and a plan of correction is due on December 17, 2008.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document an informed consent to release information in six of six client records.
The findings include:
Six client records were reviewed on November 18, 2008. The releases of information contained both "release to" and "receive from" sections. The "receive from" section of the consent to release information form contains language that detracts from an informed consent in client records # 1, 2, 3, 4, 6 and 7.
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Plan of Correction
New releases of information are being implemented in all programs by the Program Director. Director will also train & monitor the staff -implementation 12/18/08 |
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
Based on the review of client records, the facility failed to ensure that information to be released was limited to the restrictions imposed at 4 Pa. Code 255.5 in one of six client records.
The findings include:
Six client records were reviewed on November 19, 2008. A consent to release information form included the release of a legal history in client record # 2. The release of the legal history exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
Program Director will reveiw confidentiality with staff, especially in regards to legal history. New releases are also being implemented in the programs. Director will ensure implementation and training is completed - 12/22/08 |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document appropriate psychosocial evaluations in two of two outpatient records.
The findings include:
Two client records were reviewed on November 19, 2008. Psychosocial evaluations were historical repetitions of the history forms rather than an evaluation in client records # 6 and 7.
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Plan of Correction
Program Director will reveiw with staff to document appropriate psychosocial evaluations using less historical repetitions of the history forms. - 12/22/08 |