INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 7, 2019 through October 8, 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, GPASS - Asian Outpatient Counseling Service 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) (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 to whom the disclosure would be made to on a consent form in two of seven client records.
Client #3 was admitted on August 14, 2019 and was active at the time of inspection. There was a consent to release information form signed and dated by the client on August 14, 2019; however, the consent form did not include the specific name of the person to whom the disclosure was to be made.
Client # 4 was admitted on January 4, 2019 and was discharged on June 3, 2019. There was a consent to release information form signed and dated by the client on January 4, 2019; however, the consent form did not include the specific name of the person to whom the disclosure was to be made.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A training will be held on or before 10/31/2019 educating the new staff, as well as the old staff that all releases need to have a specific name of the person the release is intended for i.e.: P.O. JOHN DOW of probation or parole Dept. Any release should have the name of the person or the position of the person that the release is intended to be addressed to. The supervisor will be responsible to conduct the training and check a few of the patient's charts during staff's individual supervision and submit a form monthly listing the charts that were checked to the Facility Director. It will be the Facility Directors responsibility to see that this is done and put a copy of the form in a binder to be kept in the Facilities Directors Office locked office. |
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
The facility failed to document the date of the witness signature on a consent form in one of seven client records.
Client #2 was admitted on April 1, 2019 and was active at the time of inspection. There was a consent to release information form signed and dated by the client on August 14, 2019 to their primary care physician; however, the consent form did not include the date the witness signed the form.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A training will be held on or before 10/31/2019 for the purpose of seeing that the patient signed the consent form and the date signed, as well as the staff witnessed the signature and the date signed both dates need to match so the person looking at the form knows the that when the consent form was signed that witness was present and actually witnessed the patient sign the form. The Supervisor will be responsible to check the dates and signatures will be checked by the supervisor during random chart checks at the individual monthly staff supervision and the charts checked will be listed on a form that they were checked during the supervision. The Facility Director will be responsible for creating the form, as well as be responsible for reviewing the form and check a random sample of the charts that this was done by the supervisor and the binder that was storing these form will be in the locked supervisors office. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
The facility failed to maintain onsite a photograph of each client, which includes the patient's name and date of birth, in three of seven applicable records.
Client #1 was admitted into the buprenorphine waiver program on June 20, 2019 and was active at the time of inspection.
Client #2 was admitted into the buprenorphine waiver program on April 1, 2019 and was active at the time of inspection.
Client #3 was admitted into the buprenorphine waiver program on August 14, 2019 and was active at the time of inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
To correct the identification issue there will be a form that will have a copy of the patients divers license or non drivers license (State ID) as the first choice or prison ID with a photograph of the patient/client. If there isn't a picture ID we will get an age ID through compass, or EVS and take a picture of the patient to be placed on the form. The front desk staff will be responsible for checking company or EVS if no picture ID is collected at intake in the event there is no picture and the Compass or EVS is used for the date a picture will be taken and put on the form. The Offices supervisor will be responsible to see that this was done. A sentence on the form will state:(A picture ID must be updated every three years and a date the picture that was taken if by camera). GPASS will make every effort to get a picture ID prior to admitting the patient into the Suboxone/Buprenorphine treatment.
The facility director will make the form and the clinical supervisor provide a mandatory all staff training on this procedure by 10/31/2019. Facility Director will be responsible to see the training was done. The CEO will be responsible to see that the form was completed and in use by November 1st 2019. |