INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Axiom Family Counseling Services, 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) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form in one out of seven records reviewed.
Client #6 was admitted on February 21, 2022 and discharged on May 16, 2022. A consent form dated February 21, 2022 did not have a name of the person, agency or organization to whom disclosure is made.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
During clinical staff meetings, the Clinical Supervisor has discussed audit issues including the appropriate method of completing consent forms. Individual training was provided to the counselor who failed to add the necessary identifying information. Documentation of training was added to her personnel chart. Ongoing chart auditing will occur to ensure that all clinical staff as well as administrative staff are completing consent forms in conjunction with our policies and procedures. |