INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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) (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
The facility failed to document the date of the client's signature on release of information forms in one of eight client records reviewed.Client # 5 was admitted on January 15, 2019 and was discharged on May 13, 2019. The release of information form to the funding source was signed by the client and was signed and dated by the witness on January 21, 2019.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #5 signed a release of information form to the funding source and the facility failed to document the date of the client's signature. Client #5 is discharged . The clinical supervisor will ensure that all releases are dated through regular client file checks to make certain this does not occur again. 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 3-4-2020. |