INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 24, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Path Incorporated 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) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in three of seven client records reviewed.
Client # 1 was admitted on November 25, 2019 and was still active at the time of the inspection. The release of information form to the primary care physician was signed and dated by the witness on December 21, 2020, but the form did not document the dated signature of the client.
Client # 2 was admitted on February 5, 2020 and was still active at the time of the inspection. The release of information form to a family member was signed and dated by the witness on February 22, 2021, but the form did not document the dated signature of the client.
Client # 7 was admitted on February 4, 2020 and was discharged on September 2, 2020. The release of information form to another treatment provider was signed and dated by the witness on December 21, 2020, but the form did not document the dated signature of the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
At the time of the Initial appointment, prior to admission to SU OP services, individuals registering for service will complete all necessary documentation face-to-face in order to obtain live signatures. Staff received a comprehensive training / retraining to ensure all consents and releases of information are completed in their entirety. Individuals cannot start in the program without the forms being completed in-person. The Program Director completed the training for staff by 7.9.21. Required fields were entered into our electronic health record on 7.9.2021 to ensure compliance. All new hires will receive the training ongoing within their 2 weeks of hire.
Client #1 will complete a new PCP Release of Information 7/31/2021 or later.
Client #2 will complete a new ROI for the family member 7/31/2021 or later
Client #7 is no longer active with PATH and therefore we are unable to complete a new ROI.
Program Director will ensure the above is completed by dates specified. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness on release of information forms in two of seven client records reviewed.
Client # 1 was admitted on November 25, 2019 and was still active at the time of the inspection. The release of information form to the primary care physician was signed and dated by the client on February 18, 2020, but the form did not document the dated signature of the witness.
Client # 3 was admitted on January 30, 2020 and was still active at the time of the inspection. The release of information form to a physician was signed and dated by the client on January 30, 2020, but the form did not document the dated signature of the witness.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Updated training was completed by 7.9.2021 with staff to ensure they are aware of the proper completion of all authorizations, consents and releases of information. Training included discussion of mandatory live signatures, witness signatures, ensuring correct dates, and reviewing content with the Individual receiving treatment to confirm accuracy. The Program Director completed the training and will ensure all new hires are trained within 2 weeks of hire. Our Electronic Health Record was updated to ensure certain fields are required on consents and release of information forms.
PCP ROI for Client #1 will be signed as stated above at the next appointment and witness will provide signature as required 7/31/21 or later. A new Specialist Medical Provider ROI for Client #3 will be completed with required witness signature, if still active with that provider, 7/31/21 or later.
Program Director will ensure tasks are completed by due dates.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent form was offered to the client for release of information forms in seven of seven client records reviewed. Each client record reviewed contained a release of information form to the funding source that failed to document that a copy of the consent was offered to the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Quality Improvement staff have updated all consents, authorizations and releases to reflect documentation that Individual was offered a copy. This is a required field on all of the specified forms. The forms on our electronic health record were updated 7.9.2021 |