INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 17, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Way of Life 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) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on the release of information form in one of seven records.
Client #4 was admitted on October 23, 2023, and discharged on December 7, 2023. A release of information to a government agency was signed and dated by the client on October 23, 2023, but did not indicate a purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On 7/28/24 the clinical staff received retraining on informed and voluntary consents for the disclosure of information. Training included specifics in regards to informed and voluntary consents especially in the area of purpose of disclosure, as well as specific information that could be released for an informed and voluntary consent. To ensure future compliance consents will be reviewed during monthly chart reviews completed by the Firetree compliance team. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included a familiarization with the hours of operation in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/7/24 as part of the orientation to the project, a section was added to the facility client handbook specific to the hours of operation for the program. Each client will sign acknowledgement of understanding and reception of client handbook upon arrival to the facility. To ensure further compliance, facility director and Firetree compliance team will complete random monthly chart audits. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project which included a familiarization with the fee schedule in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/7/24 as part of the orientation to the project, a section was added to the facility client handbook specific to the fee schedule for the program. Each client will sign acknowledgement of understanding and reception of client handbook upon arrival to the facility. To ensure further compliance, facility director and Firetree compliance team will complete random monthly chart audits. |