INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 14, 2020 through October 15, 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, Hope Springs Behavioral Health 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
The project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client # 4 was admitted on March 31, 2020 and was discharged on June 24, 2020. There was documentation of communication between a County Children and Youth Services Caseworker and the facility on July 21, 2020 and July 22, 2020; however, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure the facility only utilizes voluntary consent forms from the facility and does not accept other organizational voluntary consent forms to ensure staff only utilizes the correct voluntary consent forms in accordance with DDAP standards.
To have a staff meeting on 10/23/20 to discuss the policy changes moving forward.
To complete chart audits on quarterly basis to make sure the chart is in compliance |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The project failed to document in the client record the written acknowledgement by the client that they had been notified of the right to retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in seven of seven client records reviewed.
Client #1 was admitted on March 9, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on July 20, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 14, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 31, 2020 and was discharged on June 24, 2020.
Client #5 was admitted on December 19, 2019 and was discharged on January 16, 2020.
Client #6 was admitted on June 5, 2020 and was discharged on September 9, 2020.
Client #7 was admitted on July 16, 2020 and was discharged on September 28, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To replace the Client Rights and Limits of Confidentiality and Acknowledgement form with a form that includes that the client had been notified of the right to retain civil rights and liberties except as provided by statute and that no client may be deprived of a civil right solely by reason of treatment in all of the existing records and to add the revised document into the admissions intake packet.
Had a staff meeting on 10/23/20 to inform staff to have the existing clients review, sign, and date the newly revised form and to educate staff on the new form in the intake admissions packet.
To have chart audits quarterly to ensure compliance by the Facility Director. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The project failed to document in the client record the written acknowledgement by the client that they had been notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in seven of seven client records reviewed.
Client #1 was admitted on March 9, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on July 20, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 14, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 31, 2020 and was discharged on June 24, 2020.
Client #5 was admitted on December 19, 2019 and was discharged on January 16, 2020.
Client #6 was admitted on June 5, 2020 and was discharged on September 9, 2020.
Client #7 was admitted on July 16, 2020 and was discharged on September 28, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To replace the Client Rights and Limits of Confidentiality and Acknowledgement form with a form that includes that the client had been notified that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion in all of the existing records and to add the revised document into the admissions intake packet.
Had a staff meeting on 10/23/20 to inform staff to have the existing clients review, sign, and date the newly revised form and to educate staff on the new form in the intake admissions packet.
To have chart audits quarterly to ensure the charts are in compliance by facility director. |
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
The project failed to document in the client record the written acknowledgement by the client that they had been notified that when a client is inspecting their own record, the facility or clinical director may temporarily remove portions of the records prior to the inspection, if the director determines that the information may be detrimental and that reasons for removing sections shall be documented in the record in seven of seven client records reviewed.
Client #1 was admitted on March 9, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on July 20, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 14, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 31, 2020 and was discharged on June 24, 2020.
Client #5 was admitted on December 19, 2019 and was discharged on January 16, 2020.
Client #6 was admitted on June 5, 2020 and was discharged on September 9, 2020.
Client #7 was admitted on July 16, 2020 and was discharged on September 28, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To replace the Client Rights and Limits of Confidentiality and Acknowledgement form with a form that includes that the client had been notified that when a client is inspecting their own record, the facility or clinical director may temporarily remove portions of the records prior to the inspection, if the director determines that the information may be detrimental and that reasons for removing sections shall be documented in the record in all of the existing records and to add the revised document into the admissions intake packet.
Had a staff meeting on 10/23/20 to inform staff to have the existing clients review, sign, and date the newly revised form and to educate staff on the new form in the intake admissions packet.
To have the charts audited quarterly to ensure the charts are in compliance by the facility director. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The project failed to document in the client record the written acknowledgement by the client that they had been notified that clients have the right to appeal a decision limiting access to their records to the director in seven of seven client records reviewed.
Client #1 was admitted on March 9, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on July 20, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 14, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 31, 2020 and was discharged on June 24, 2020.
Client #5 was admitted on December 19, 2019 and was discharged on January 16, 2020.
Client #6 was admitted on June 5, 2020 and was discharged on September 9, 2020.
Client #7 was admitted on July 16, 2020 and was discharged on September 28, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To replace the Client Rights and Limits of Confidentiality and Acknowledgement form with a form that includes that the client had been notified that clients have the right to appeal a decision limiting access to their records to the director in all of the existing records and to add the revised document into the admissions intake packet.
Had a staff meeting on 10/23/20 to inform staff to have the existing clients review, sign, and date the newly revised form and to educate staff on the new form in the intake admissions packet.
To have the charts audited quarterly to ensure the charts are in compliance by the facility director.
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709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The project failed to document in the client record the written acknowledgement by the client that they had been notified that clients have the right to to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in seven of seven client records reviewed.
Client #1 was admitted on March 9, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on July 20, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 14, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 31, 2020 and was discharged on June 24, 2020.
Client #5 was admitted on December 19, 2019 and was discharged on January 16, 2020.
Client #6 was admitted on June 5, 2020 and was discharged on September 9, 2020.
Client #7 was admitted on July 16, 2020 and was discharged on September 28, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To replace the Client Rights and Limits of Confidentiality and Acknowledgement form with a form that includes that the client had been notified of the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in all of the existing records and to add the revised document into the admissions intake packet.
Had a staff meeting on 10/23/20 to inform staff to have the existing clients review, sign, and date the newly revised form and to educate staff on the new form in the intake admissions packet.
To have the charts audited quarterly to ensure the charts are in compliance by the facility director.
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709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
The project failed to document in the client record the written acknowledgement by the client that they had been notified that clients have the right to submit rebuttal data or memoranda to their own records in seven of seven client records reviewed.
Client #1 was admitted on March 9, 2020 and was a current client at the time of the inspection.
Client #2 was admitted on July 20, 2020 and was a current client at the time of the inspection.
Client #3 was admitted on August 14, 2020 and was a current client at the time of the inspection.
Client #4 was admitted on March 31, 2020 and was discharged on June 24, 2020.
Client #5 was admitted on December 19, 2019 and was discharged on January 16, 2020.
Client #6 was admitted on June 5, 2020 and was discharged on September 9, 2020.
Client #7 was admitted on July 16, 2020 and was discharged on September 28, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To replace the Client Rights and Limits of Confidentiality and Acknowledgement form with a form that includes that the client had been notified that clients have the right to submit rebuttal data or memoranda to their won records in all of the existing records and to add the revised document into the admissions intake packet.
Had a staff meeting on 10/23/20 to inform staff to have the existing clients review, sign, and date the newly revised form and to educate staff on the new form in the intake admissions packet.
To have the charts audited quarterly to ensure the charts are in compliance by the facility director.
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