Observations
Based on the review of client records, the project failed to offer a copy of release of information form in one of four client records reviewed.
Client #2 was admitted to residential program level of care on December 22, 2025 and was discharged on December 22, 2025. The informed and voluntary consent form for Lehigh County probation was signed and dated December 22, 2025; however, there was no documentation that a copy was offered. Documentation in client chart verifies contact was made by facility staff to probation office on December 23, 2025.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the failure to comply with the requirement that a copy of the signed Release of Information be offered to the client, staff were verbally addressed during the all-staff meeting on 01/08/2026, and expectations were reviewed. During a scheduled group clinical supervision by 01/31/2026 the clinical team, including the Admissions Coordinator, will receive additional training from the Facility Director. This training will include review of confidentiality requirements and provision of a mock compliant Release of Information form. Attendance and training will be documented in the group supervision note by the Clinical Supervisor.
The Clinical Supervisor will conduct monthly chart audits during individual supervision with the clinical team starting 02/01/2026, and any identified deficiencies will be addressed immediately through corrective feedback and additional training as needed. Audit results will be documented and maintained for licensing review.
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