INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2019 to July 30, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, PHMC Pathways to Recovery 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
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.Client # 1 was admitted on May 14, 2019 and was active at the time of the inspection. There was documentation of communication with a transportation company on May 31, 2019; however, there was no consent to release information on file prior to the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consents were completed by each active participant for the transportation company and this consent has been incorporated into the case management assessment. Staff were trained by the Program Director on 7/31/2019 on the informed and voluntary consent release information form procedures. Ongoing compliance will be monitored by the Clinical Director through weekly chart review. |
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
The facility failed to document the name of the person, agency or organization to whom the disclosure would be made to on a consent form in one of seven client records reviewed.Client # 7 was admitted on January 30, 2019 and was discharged on March 15, 2019. There was a consent form to "Probation" signed and dated by the client on January 30, 2019; however, the consent form failed to include the specific name of the person, agency or organization.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director trained staff on thoroughly completing informed consent release documentation on 7/31/19. Clinical Director will monitor during weekly chart reviews for compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to provide documentation that client #7 was notified, in writing, of the facility's decision to involuntarily terminate the client from treatment. Client #7 was admitted to the partial hospitalization level of care on January 30, 2019 and was involuntarily discharged on March 15, 2019.The findings were discussed with facility staff during the licensing inspection.
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Plan of Correction
The Program Director and Clinical Director will train staff on 8/29/19 on the procedures for involuntary termination. A template will be created to ensure clients are informed of the reason for the termination and the process for requesting reconsideration of a decision terminating their treatment.
The Clinical Director and/or Program Director will provide oversight and monitoring of this necessary documentation. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
The facility failed to notify the Department within 3 days following an unusual incident, which involved an off-site client death that was reported to the facility on February 8, 2019.These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
To the extent permitted by State and Federal confidentiality laws, Pathways to Recovery will file written unusual incident reports within 3 business days following an unusual incident. The Clinical Director and Program Director will provide a staff training on 9/16/19 to train all staff. Both the Clinical and Program Director will be responsible to ensuring unusual incident reports are submitted thoroughly and promptly. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice a week, in six of seven client records reviewed in the partial hospitalization activity.Client # 1 was admitted on May 14, 2019 and was active at the time of the inspection. Documentation of two individual sessions per week was not completed for the weeks of:June 2, 2019 to June 8, 2019June 9, 2019 to June 15, 2019June 16, 2019 to June 22, 2019June 23, 2019 to June 29, 2019Client # 2 was admitted on May 24, 2019 and was active at the time of the inspection. Documentation of two individual sessions per week was not completed for the weeks of:June 2, 2019 to June 8, 2019June 9, 2019 to June 15, 2019June 23, 2019 to June 29, 2019Client # 3 was admitted on May 28, 2019 and was active at the time of the inspection. Documentation of two individual sessions per week was not completed for the weeks of:June 2, 2019 to June 8, 2019June 16, 2019 to June 22, 2019June 23, 2019 to June 29, 2019Client # 4 was admitted on March 28, 2019 and was discharged on June 12, 2019. Documentation of two individual sessions per week was not completed for the weeks of:May 19, 2019 to May 25, 2019May 26, 2019 to June 1, 2019Client # 6 was admitted on January 29, 2019 and was discharged on April 29, 2019. Documentation of two individual sessions per week was not completed for the weeks of:March 17, 2019 to March 23, 2019Client # 7 was admitted on January 30, 2019 and was discharged on March 15, 2019. Documentation of two individual sessions per week was not completed for the weeks of:February 10, 2019 to February 16, 2019These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During weekly supervision, the Clinical Director will monitor compliance and the Program Director will provide oversight to ensure compliance of individual counseling being provided to all clients at least twice weekly. A request for a compliance report to be created by the IT Department was submitted on 8/1/19. This report will help support the compliance of two individual sessions weekly.
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