INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gaudenzia Drc 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) 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 client records, the facility failed to document an informed and voluntary consent from the client prior to disclosure of information in two of seven client records.
The findings included:
Seven client records were reviewed on October 16, 2014. Seven client records were required to document an informed and voluntary consent from the client prior to the disclosure of information.
Client #3 was admitted to treatment on July 14, 2014 and was still active in treatment at the time of the inspection. Two consents to release information were signed and dated on July 14, 2014. The two consents did not include the name of the person or agency to whom the information was to be disclosed, the specific information discolsed, the purpose of the disclosure, or the expiration date of the consent.
Client #4 was admitted to treatment on July 30, 2014 and was still active in treatment at the time of the inspection. One consent to release information was signed and dated on July 30, 2014. The consent did not include the name of the person or agency to whom the information was to be disclosed, the specific information discolsed, the purpose of the disclosure, or the expiration date of the consent. Another consent to release information was signed and dated on July 30, 2014. That consent indicated release of information to "no specific family".
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All informed and voluntary consent forms will be signed and dated by the client and a clinical staff member. The consent form will include the specific information disclosed, the purpose of the disclosure, and the expiration date of the consent.
There will be a training facilitated by the Outpatient Program Director on the completion of a Consent form.
Completion Date: 1/1/15
Status:
Date:
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709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records the facility failed to offer the client a copy of a client consent in one of seven records reviewed.
The findings include:
Seven client records were reviewed on October 16, 2014. One of seven client rcords failed to indicate a copy of client consents to release information were offered to the client.
Client record #4 had no documentation that the client was offered a copy of consents to release information in five out of eight consents to release.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
All informed and voluntary consent forms will be signed and dated by the client and a clinical staff member. The client will be offered a copy of the consent form. The client will indicate on the form that they have been offered a copy of the document and they have 'Accepted' or 'Refused' a copy of it.
There will be a training facilitated by the Outpatient Program Director on the completion of a Consent form. Completion Date:
1/1/15
Status:
No POC
Date:
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