Observations
Based on a review of client records, the facility failed to ensure that the specific information disclosed contained on consent to release client information forms adhered to the restrictions imposed at 4 Pa. Code, Subsection 255.5 (b) (1-5), in two of seven client records reviewed.
The findings include:
4 Pa. Code 255.5 (b) (1-5) states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Seven client records were reviewed on April 30, 2014 for documentation of consent to release client information forms. The facility failed to ensure that the specific information disclosed on consent to release client information forms contained in client records # 1 and 2 adhered to the restrictions imposed at 4 Pa. Code, Subsection 255.5 (b) (1-5).
Client record # 1 included two consent to release client information forms for funding entities. The specific information disclosed to the funding entities listed on both consent to release client information forms exceeded 4 Pa. Code, Subsection 255.5 (b) (1-5). The consent forms permitted the facility to release the client's mental health history and history of domestic violence to the funding entities.
Client record # 2 included a consent to release client information form for a law enforcement agency. The specific information disclosed to the law enforcement agency listed on the consent to release client information form exceeded 4 Pa. Code, Subsection 255.5 (b) (1-5). The consent form permitted the facility to release "any and all allowable and necessary info pertaining to probation requirements" to the law enforcement agency.
The facility director confirmed the findings.
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Plan of Correction
Informed and voluntary written consent will be obtained from clients prior to facility staff disclosing information. These consents will adhere to the following five points only: (1) Whether the client is or is not in treatment (2) Client's prognosis (3) The nature of the project (4) A brief description of the client's progress (5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
All copies of consents will remain in the client record.
Clinical Supervisor reviewed the confidentially regulations with all staff in a meeting on May 9, 2014. To further insure compliance the Clinical Supervisor will review client records on a monthly basis.
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