INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on May 8-9, 2019. Based on the findings of the on-site inspection, Outside In Pathway to Recovery Outpatient Services was found to not 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to not permit in the facility heaters that are not permanently mounted or installed.
During a review of records on May 8-9, 2019, there was a Health and Safety Report completed on January 17, 2019 at 9:30 am by the Clinical Supervisor. It stated in the report that the "space heater had an odor" and the corrective action taken was "unplugged the space heater and put it in the trash because it was giving off a strange odor".
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will not permit in the facility heaters that are not permanently mounted or installed.
The Clinical Director will add "heaters that are not permanently mounted or installed" to the staff meeting agenda for June 17, 2019. All staff will attend this meeting and will learn that space heaters are not permitted in the facility. The Clinical Supervisor will add a reminder regarding the policy on space heaters to the staff meeting agenda in October as a refresher once cooler temperatures begin. The Clinical Director will monitor the clinic for any space heaters and immediately remove from the premises. |
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 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 the name of the person, agency or organization to whom the disclosure is made.
During a review of records on May 8-9, 2019, Client #1 had a consent form to PCP (none at this time) that was signed by Client #1 and was dated for December 14, 2018. Client #1 had been admitted on December 14, 2018 and was discharged on April 29, 2019.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review "how to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record" during the staff meeting scheduled for June 17, 2019. This review will focus on the policy that "none at this time" is not an appropriate response to a name of a person on a voluntary consent form. The specific chart cited in this review of records was Client #1- Client #1 had been admitted on December 14, 2018 and was discharged on April 29, 2019 therefore no specific correction was able to be made to the chart. |
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
The facility failed to 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 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).
During a review of records on May 8-9, 2019, Client #4 had a consent to release information to their doctor for the purpose of treatment planning, continuity of care, assessment, collaboration and discharge planning that included the five allowable points of 42 CFR. The release was not signed or dated by Client #4. Client #4 had been admitted on November 9, 2018 and was still active during the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review how to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record during the staff meeting scheduled for June 17, 2019. This will include a review of the requirements for consent including: consent must be in writing and include, but not be limited to 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).
During a review of records on May 8-9, 2019, Client #4 had a consent to release information to their doctor for the purpose of treatment planning, continuity of care, assessment, collaboration and discharge planning that included the five allowable points of 42 CFR. The release was not signed or dated by Client #4. Client #4's signature was obtained on May 16, 2019.
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