Observations
Based on a June 2 through 6, 2008 review of client records, the facility failed to obtain an informed and voluntary consent in two of twenty records reviewed, # 23 and 24. Specific information to be disclosed to the clients's employers exceeded that allowed by 4 Pa. Code 255.5(a)(6). The information to be disclosed included the progress, presence and compliance with treatment letters, diagnosis, nature of program and prognosis in one record, #23. Information to be disclosed included the progress and diagnosis in one record, #24.
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Plan of Correction
Records #23 and 24 were in the partial hospital program. Outpatient coordinator will instruct the counselor working in the partial program on the specific information allowed to be released under 4 Pa.Code 255.5 [a] [6]. This will occur by 6/28/2008. Compliance will be monitored by outpatient coordinatorin monthly record reviews on 10% of all new admissionsto the partial program until 12/31/2008. |