INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 31, 2006 through June 2, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 29, 2006.
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Plan of Correction
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709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
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Observations
The annual report for period ending June, 30, 2005 failed to include a statement of disclosing the names of officers, directors and principal shareholders.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
The organization failed to secure client records at the licensed facility. Outpatient treatment activities provided at the Berks County Prison is authorized by the Department, however, client records need to be maintained at the Washington Street facility.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
Organizational authorization to release forms include a parent, guardian or representative sign- off requirement. Only the person to whom the information pertains may consent to the release of information.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Three of three client records, where the client had been successfully discharged, failed to provide documentation of an aftercare plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.93(a)(10) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Three of three files reviewed on June 2, 2006 failed to document discharge summaries where the clients had been discharged more than seven days prior to the review.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |