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 March 17, 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, Public Health Management Corporation d/b/a 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) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in two of seven client records reviewed.
Client # 2 was admitted on January 8, 2021 and was still active at the time of the inspection. The release of information forms to another treatment provider, an emergency contact and a parole officer were signed and dated by the client on January 8, 2021, but all of the release forms failed to document the specific information to be disclosed.
Client # 3 was admitted on February 19, 2021 and was still active at the time of the inspection. The release of information forms to another treatment provider and a government agency were signed and dated by the client on February 19, 2021, but both of the release forms failed to document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Interim Program Director scheduled a training on Release of Information for all staff that was held on 4/7/2021. This training was conducted by Pathways Quality Manager and Clinical Director. The training included reviewing documentation of specific information to be released when completing request for Release of Information forms. Staff's participation was documented by attendance sign in sheet.
All releases of information consents for Participant #2 and #3 were reviewed, updated and completed to meet standard by 4/9/21.
Moving forward Staff will accurately complete consents documenting the specific information to be disclosed. Clinical Director will monitor and audit charts monthly to ensure acuuracy of consents. Pathways Quality manager will audit participant charts quarterly to ensure documentation of consents are accurate and completed in entirety.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in two of seven client records reviewed.
Client # 2 was admitted on January 8, 2021 and was still active at the time of the inspection. The release of information forms to another treatment provider, an emergency contact, a government agency, and a parole officer were signed and dated by the client on January 8, 2021, but all of the forms failed to document the purpose of the disclosure.
Client # 3 was admitted on February 19, 2021 and was still active at the time of the inspection. The release of information form to and a government agency was signed and dated by the client on February 19, 2021, but both of the release forms failed to document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Interim Program Director scheduled a training on Release of Information for all staff that was held on 4/7/2021. This training was conducted by Pathways Quality manager and Clinical Director. The training included reviewing documentation of purpose and specific information to be released when completing request for Release of Information forms. Staff's participation in training was documented by attendance sign in sheet.
All releases of information consents for Participant #2 and #3 were reviewed, updated and completed to meet standard by 4/9/21.
Moving forward Admission Coordinator and Therapist will accurately document purpose of disclosure when completing all necessary consent to release information forms as needed. Clinical Director and Pathways Quality manager will oversee and audit participant charts monthly to ensure correct completion of consents to release information.
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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 client records, the facility failed to document the dated signature of the client on release of information forms in two of seven client records reviewed.
Client # 1 was admitted on December 9, 2020 and was still active at the time of the inspection. The release of information forms to another treatment provider and a government agency were signed and dated by the witness on December 9, 2020, but both of the release forms failed to document the dated signature of the client.
Client # 4 was admitted on November 19, 2020 and was discharged on January 21, 2021. The release of information forms to another treatment provider, a government agency, a parole officer, a transportation company, a primary care physician and an emergency contact were signed and dated by the witness on November 19, 2020, but all of the release forms failed to 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
Interim Program Director scheduled a training on Release of Information Consents for all staff that was held on 4/7/2021. This training was conducted by Clinical Director and Pathways Quality Manager. The training included reviewing consents and guidelines regarding dates and signatures. Participants #1 was asked to sign and date all written consents to release information by 4/9/21 even though the participant had previously given verbal consent. Pathways therapist attempted to contact participant #4 who had been discharged as of 1/21/21. to have the noted consents properly signed and updated but was unable to contact for correction. Moving forward to ensure compliance,the clinical director and Pathways Quality officer will review client consents in charts quarterly to ensure that consents are totally and properly completed including signatures and dates. |