INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6, 2006 to November 8, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on December 13, 2006.
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Plan of Correction
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709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
The facility failed to document the employees's right to submit rebuttal data or memoranda to his own records.
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Plan of Correction
As of 12-1-06 the policy in question 709.26 (e)(3) has been amended to include the statement that Employees have the right to submit data or memoranda to his/her records. The data or memoranda will be placed in the Personnel Record.
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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 facility confidentiality policy for 4 Pa. Code subsection 255.5 indicates that client identifying information can be released "with or without" the client's informed written consent. This is incorrect and is inconsistent with state law at 71 P. S. subsection 1690.108(b) and federal regulations at 42 CFR Part 2, Subparts A through E.
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Plan of Correction
As of 12-1-06 the facility confidentiality policy for 4 Pa Code subsection 255.5 has been amended to state client identifying information can be released only with the client's informed written consent. The phrase without has been removed from the policy. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Individual treatment plans are to be completed within 15 days according to agency policy. The treatment plans were late in client records #1 #,2 #,3, #4 and #7. All treatment plans must be completed within the time frame identified by facility policy.
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Plan of Correction
As of 12-1-06 the facility has revised the agency policy on time frames for developing the comprehensive treatment plans. The entire treatment staff have been provided with the new policy and educated on the time frames to complete the comprehensive treatment plan. The individualized plans will be completed, signed and dated by the therapist within the time frames outlined in the new policy for each client admitted to outpatient treatment. All treatment staff members were provided with training on completing comprehensive treatment plans and the new policy on 11-30-06. The new policy became effective on 12-01-06. Treatment plan compliance will be checked regularly during monthly quality assurance reviews by the Treatment Supervisor.
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