Observations
Seven client records were reviewed on August 9, 2016. The facility failed to obtain a valid consent to release information for client records # 1, 3, 4, 5, 6, and 7.
Client # 1 was admitted into treatment on 8/2/16 and was still active in treatment. A consent to release to an insurance company, signed and dated on 8/2/16, permitted the release of the client's history.
Client # 3 was admitted into treatment on 8/27/15 and was still active in treatment. A consent to release to an insurance company, signed and dated on 3/1/17, permitted the release of the following information: history, legal issues, lab work, and psychological assessment.
Client# 4 was admitted into treatment on 9/28/16 and was discharged on 3/2/17. A consent to release to an insurance company, signed and dated on 9/28/16, permitted the release of the following information: history, lab work, psychological assessment, psychological evaluation, and legal issues/concerns.
Client # 5 was admitted into treatment on 8/31/16 and was discharged on 1/13/17. A consent to release to an insurance company, signed and dated on 8/31/16, did not specify the information to be disclosed.
Client # 6 was admitted into treatment on 8/26/16 and was discharged on 11/11/16. A consent to release to an insurance company, signed and dated on 8/26/16, did not specify the information to be disclosed.
Client # 7 was admitted into treatment on 1/25/17 and was discharged on 6/30/17. A consent to release to an insurance company, signed and dated on 1/26/17, permitted the release of the following information: history, lab work, psychological assessment, and psychological evaluation.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
§ 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.
POC: In the new EHR system we have updated releases for specific entities ? insurance companies, pharmacies ? that list what is to be released IAW PA Code 255.5. It includes: whether the client is or is not in treatment, the prognosis of the client, the nature of the project, a brief description of the progress of the client and a short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Anticipated Completion Date: August 9, 2017. Program Director updated the releases in the EHR and informed all staff to use the updated releases when working with clients. Executive Director will review charts bi-monthly to ensure the correct format is used.
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Observations
Five client records were reviewed for the documentation of a psychosocial evaluation on August 9, 2017. The facility failed to document a psychosocial evaluation for client records # 4, 5, 6, and 7.
Client # 4 was admitted into treatment on 9/28/16 and was discharged on 3/2/17.
Client # 5 was admitted into treatment on 8/31/16 and was discharged on 1/13/17.
Client # 6 was admitted into treatment on 8/26/16 and was discharged on 11/11/16.
Client # 7 was admitted into treatment on 1/25/17 and was discharged on 6/30/17.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.91. Intake and admission. (b) Intake procedures shall include documentation of: (6) Psychosocial evaluation.
POC: Clinical Director discovered a technical glitch in our previous EHR system with regard to the psycho-social evaluation summary. After identifying the problem, our previous contractor made corrections. When we changed systems in April 2017, the data that flowed from our previous system reverted and the summary was lost. Our new EHR requires review before the clinician may release notes for billing giving the Clinical Director the opportunity to ensure the evaluation summary is complete.
Anticipated Completion Date: August 12, 2017. Clinical Director will review clinical notes weekly and ensure the summaries of all new clients are completed before releasing the note. Executive Director will make random reviews monthly for the next three months to ensure the system is working.
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