INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 14, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia, 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
Seven client records were reviewed on June 14, 2017. The facility failed to obtain a consent to release information form for information released to a treatment provider in one of seven client records reviewed, specifically client record #1.
Client #1 was admitted into treatment on February 6, 2017 and was still an active client at the time of the inspection. The client record contained documentation indicating that the facility released patient identifying information to a treatment provider on February 7, 2017 and failed to obtain an informed and voluntary consent prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all staff in service training will be held on 7-7-17. PA Code 255.5 will be reviewed. All staff will be reminded that no information will be released to outside sources without a client signed release of information. All correspondence documented in the client chart will be monitored monthly by Program Management in the CQI process to ensure compliance. All new clinical hires will be required to enroll in Confidentiality training. Client # 1 has been incarcerated - unable to obtain appropriate release. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Seven client records were reviewed on June 14, 2017. The facility failed to document written acknowledgement by clients that they have been notified of all their rights as the following rights were not listed on the Client Rights form or in the Orientation Manual:
* Reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A correction to the Client Orientation Handbook was completed on 6-15-17. The correction included the addition of the wording "Reasons for removing sections shall be documented in the record." Staff were alerted to this change on 6-15-17. On 7-7-17 this new addition will be reviewed at the all staff meeting. |