INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on November 12-14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Discovery House Cu-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 investigation and a plan of correction is due on December 23, 2008.
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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 interviews with staff, clients, and the Clearfield County Probation office, a review of a probation violation document and a review of client records and administrative materials, the facility failed to ensure that an informed consent to release client identifying information was documented for each release of information to outside agencies.
The findings include:
Client record #11 was reviewed in response to a complaint regarding confidentiality during the onsite licensing inspection of November 12-14, 2008. The client record had no consent to release information to the Clearfield County Probation staff. Interviews with informants including Clearfield County Probation personnel, patients who filed complaints and facility staff , as well as documentation from Clearfield County Probation personnel, verified that a disclosure of information was made to Probation office staff without the patient's written consent.
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Plan of Correction
Insevices will be held by the Program Director and the Clinical Supervisor to explain the importance of maintaining confidentiality and the importance of releases. After the training is completed all employees will resign the confidentiality Statement. If more education is needed to ensure compliance we will send individuals to an outside confidentiality trainig.The Clinial Supervisor and Program Director will monitor compliance through chart audits. |
709.17(a)(5) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
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Observations
Based on interviews with staff, clients, and the Clearfield County Probation office, a review of a probation violation document and a review of client records and administrative materials, the facility failed to ensure that treatment plans were written by the staff assigned responsibility for formulating individual client treatment plans.
The findings include:
During interviews conducted on November 14, 2008 with staff and clients at the facility, it was disclosed that the facility director wrote treatment plans for counselors and did not identify herself as the author of the treatment plans.
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Plan of Correction
We will work with our software division to install a safety device to ensure that treatment plans are written by the staff assiigned. The Program Director will continue to monitor treatment plans but will now due it in conjuction with the Clinical Supervisor to ensure compliance. |