INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on May 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, GPASS - Asian Outpatient Counseling Service 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.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form in two of seven client records reviewed.
Client #4 was admitted February 19, 2019 and was discharged April 30, 2021. There was documentation of billing to the funding source during the treatment episode; however, there was no consent form on file prior to the disclosures of information.
Client #7 was admitted December 23, 2019 and was discharged April 14, 2021. There was documentation of billing to the funding source duringt he treatment episode; however, there was no consent form on file prior to the disclosures of information.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Consent forms were filled out by the front desk staff then the intake clinical staff did the admission.
The process was changed to a person will get an appointment from the front desk and the admission clinical staff will be responsible to fill out the consent forms with the client during the actual admission. The consent forms were arranged that the first 3 forms are mandatory and the other six will depend on what is needed. The clinician will have the other forms filled in as well as signed and dated by the client and the clinician. At no time will the client be given the forms and told to fill them out and sign. A start date and end date will be on each form. The clinical supervisor will see each chart after admission to check the forms are filled out, signed and dated properly. |
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 a review of client records, the facility failed to document the name of the person to whom the disclosure was to be made to on informed and voluntary consent forms in five of seven client records reviewed.
Client #1 was admitted on December 2, 2020 and was active at the time of inspection. A release of information form to a primary care physician was signed and dated by the client on December 2, 2020; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure was to be made.
Client #2 was admitted on October 21, 2020 and was active at the time of inspection. Release of information forms to a primary care physician, a government agency, and an emergency contact were signed and dated by the client on October 21, 2020; however, all of the consent forms did not include the specific name of the person, agency or organization to whom the disclosure was to be made.
Client #4 was admitted February 19, 2019 and was discharged April 30, 2021. A release of information form to a primary care physician was signed and dated by the client on February 19, 2019; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure was to be made.
Client #5 was admitted February 26, 2020 and was discharged April 16, 2021. Release of information forms to a primary care physician and an emergency contact were signed and dated by the client on February 26, 2020; however, both consent forms did not include the specific name of the person, agency or organization to whom the disclosure was to be made.
Client #6 was admitted September 1, 2020 and was discharged March 11, 2021. Release of information forms to a primary care physician, an emergency contact, and a government agency were signed and dated by the client on February 26, 2020; however, all of the consent forms did not include the specific name of the person, agency or organization to whom the disclosure was to be made.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The forms are the responsibility of the admission clinician to see that the name of the person or agency is filled out. If the person doesn't know and is going to get the information a note will be made and that form will be blank. The clinician that does the admission will be responsible to see that the form not filled out gets completed. If the client doesn't have a primary care physician they will be referred tp Project Home if on Medicade to get a PCP. The original clinical staff filling out the release forms with the client will be responsible to see the forms are filled and out properly signed by the client and witnessed by the clinician with a start and end date on the form. The clinical supervisor will check every new admission chart to oversee this was done properly. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document that treatment plans were reviewed and updated at least every 60 days in four of seven client records reviewed.
Client #1 was admitted on December 2, 2020 and was active at the time of inspection. A comprehensive treatment plan was completed on December 17, 2020 and an update was due no later than February 17, 2021. However, the treatment plan update was not completed until March 5, 2021.
Client #4 was admitted February 19, 2019 and was discharged April 30, 2021. A treatment plan update was completed on January 8, 2021 and the next update was due no later than March 8, 2021. However, the treatment plan update was not completed at the time of the inspection.
Client #6 was admitted September 1, 2020 and was discharged March 11, 2021. A treatment plan update was completed on November 18, 2020 and the next update was due no later than January 18, 2021. However, the treatment plan update was not completed at the time of inspection.
Client #7 was admitted December 23, 2019 and was discharged April 14, 2021. A treatment plan update was completed on September 11, 2020 and the next update was due no later than November 11, 2020. However, the treatment plan update was not completed until December 29, 2020. Additionally, a treatment plan update was completed on December 29, 2020 and the next update was due no later than March 1, 2021. However, the treatment plan update was not completed at the time of inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The initial treatment plans will be done the day of admission by the clinician doing the intake/admission. The new quality improvement person (QI) will be spot checking the counselors charts for treatment plans according to the due date. A log will be put into effect on the date the treatment plans are due and clinical staff reminded to complete the treatment plans on time. The Assistant Clinical Director will be responsible to see the QI appointed staff is checking on the treatment plans. |