INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 30, 2008 - July 2, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Fayette County Drug and Alcohol Commission, 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 and a plan of correction is due on July 28, 2008.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of staffing material and documentation and on the computation of the ratio of full time equivalent (FTE) counselors and counselor assistants on July 1, 2008, the facility failed to provide for a full-time clinical supervisor.
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Plan of Correction
The Administrative Team at Fayette County Drug & Alcohol Commission will reinstate one of our treatment specialists back to her full time clinical supervisory position. This will fulfill the 8:1 ratio of counselors to clinical supervisor. This action will be completed on July 15, 2008. |
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 the client records on July 2, 3008, the facility failed to have a Qualified Service Organization Agreement (QSOA) executed with the Quest Diagnostics laboratory, and did not have the clients sign a consent to release information form for releases of information to Quest Diagnostics for the purpose of having urinalysis drug screens completed in two of two client records where such documentation was required. Refer to client records # 8 & 10.
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Plan of Correction
On July 2, 2008, after the Licensing visit ended, a QSOA was faxed from Fayette County Drug & Alcohol Commission to Quest Diagnostics Laboratory. The signed QSOA was faxed back the same day. Because this Qualified Service Organization Agreement is one of the nine exceptions to the general rule of non-disclosure, it permits FCDAC to release information without a written consent signed by the client. |