INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 January 6, 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, Positive Pathways 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 document an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client #3 was admitted on May 26, 2020 and discharged on September 24, 2020. Two consents to release information dated May 26, 2020 had "telehealth exception" written in lieu of a client signature.
Client #4 was admitted on August 18, 2020 and is currently an active patient. Two consents to release information dated August 18, 2020 had "telehealth exception" written in lieu of a client signature.
Client #5 was admitted on March 19, 2020 and is currently an active patient. Two consents to release information dated April 27, 2020 had "telehealth exception" written in lieu of a client signature.
Client #6 was admitted on October 27, 2020. One consent to release information dated October 27, 2020 had "telehealth exception" written in lieu of a client signature.
Client #7 was admitted on August 3, 2020 and discharged on September 1, 2020. Three consents to release information dated July 31, 2020 had "telehealth exception" written in lieu of a client signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 (c) Confidentiality
Positive Pathways changed from the standard operating procedure for having patients physically sign informed and voluntary consent forms when COVID-19 presented in March 2020. The office transitioned to telemedicine and restricted patient access to the offices. With other notes/documents being exempt from physical signature, Positive Pathways mistakenly believed informed consent forms were included. Starting 3/1/2021, Positive Pathways will return to having informed consent forms signed by the patient at the office. Staff have already received their first round of vaccinations and a 3/1/2021 start date will allow for their second shots to be completed. In addition, Positive Pathways will sanitize and maintain social distance when patients present at the office. The clinical supervisor will be responsible for ensuring compliance by completing monthly chart audits. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of client records, the facility failed to document an initial drug-screening urinalysis and random monthly urinalysis at least monthly thereafter.
Client #4 was admitted on August 18, 2020 and is currently an active patient. There were no urine screens documented in client record #4.
Client #5 was admitted on March 19, 2020 and is currently an active patient. There were no urine screens documented in client record #5.
Client #6 was admitted on October 27, 2020 and is currently an active patient. There were no urine screens documented in client record #6.
Client #7 was admitted on August 3, 2020 and discharged on September 1, 2020. There were no urine screens documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 2, 2019 annual licensing inspection.
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Plan of Correction
715.14 (a) Urine Testing
Positive Pathways apologizes for the departure from our standard operating procedure for collecting an initial urine screen and random screens at least monthly. Positive Pathways had corrected the policy on initial urine screens based on the 2019 inspection. When COVID-19 presented in March 2020, the office transitioned to telemedicine and restricted patient access to the offices. With areas of practice being provided accommodations by the State, Positive Pathways believed the initial urine screens and monthly screens were included in the accommodations and also was in the best interest of patient and staff safety. Starting 3/1/2021, Positive Pathways will return to its urine collection policy as it pertains to initial urine screens and at least monthly urine screens. Staff have already received their first round of vaccinations and a 3/1/2021 start date will allow for their second shots to be completed. In addition, Positive Pathways will sanitize and maintain social distance when patients present at the office. After the initial urinalysis collection, the patients will subsequently receive an electronic prescription for a urinalysis collection at Quest. This will allow the patient to go to any Quest location that is convenient and provide a urine for collection. The clinical supervisor will be responsible for ensuring compliance by completing monthly chart audits. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence.
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