Observations
Based on a review of client records, the project failed to document informed and voluntary consent to release forms that complied with Pa Code 255.5.The findings include:4 Pa. Code 255.5 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 Eight client records were reviewed on February 10, 2016. The project failed to document informed and voluntary consent to release forms in all client records reviewed, # 1, 2, 3, 4, 5, 6, 7 and 8. 1. The project has a "Managed Care/Insurance Company Authorization to Release Information Form" that all clients sign and agree to consent to release. The "Managed Care/Insurance Company Authorization to Release Information Form" is a project wide template form. The other box is checked off on this template form with the pretext "level of care evaluations, Authorizations, Status reports and Recommendations, Chart contents." The release or documentation of the release of the client's "level of care evaluations and chart contents" does not comply with the stipulations of 255.5.2. In addition, the project has a form titled "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company - The Light Program/Life Counseling Services/Rehab After Work," that was revised 10/15.The form documents, "My signature below indicates my permission for The Light Program/Life Counseling Services/Rehab After Work to bill my insurance for payment. I give my permission to disclose information such as my diagnosis, my medication and dates I will be attending, as well as other pertinent information in order for my insurance company to grant authorization of my attendance." The release or documentation of the release of the client's "medication and dates I will be attending as well as other pertinent information in order for my insurance company to grant authorization of my attendance" does not comply and exceeds the limitations imposed at 255.5.3. Lastly, client # 1, a minor was admitted to the facility on December 1, 2015, and was still an active client at the time of inspection on 2/10/2016. On December 1, 2015, client # 1's parent signed a "Declaration of Custody and Consent to Therapy" form which does not comply with state and federal regulations. The consent documents:"Please choose from one of the following three options regarding your custody arrangement for the above named patient:-I have full legal custody of this client. I have complete authority to make decisions regarding my child's mental health needs.-There is no legal declaration of custody for this client. I have complete authority to make decisions regarding my child's mental health needs.-I share legal custody for this child. I understand that LCS must contact the client's other legal guardian before providing treatment for this client, and I agree to this contact.Signature and permission of other legal guardian for child to receive therapy:My signature below indicates that I have read and understand this form and give permission for my child to receive therapy:"Minors seeking substance abuse treatment must be treated as if they have reached the age of majority; thus the facility is bound by state and federal confidentiality laws regarding minors in treatment. Please refer to the following laws and regulations:State Law - 71 P.S. subsection 1690.112 andFederal Regulation 42 C.F.R. Part II, subsection 2.14(b) The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Site Director conducted a training on Confidentiality with staff members during weekly staff meeting on March 9, 2016. During this meeting, Site Director reviewed regulations and policies regarding client confidentiality, 4Pa. Code 255.5. The current Managed Care Consent Form will be edited to utilize proper terminology and stay within the 4Pa. Code 255.5 regulation of confidentiality. The new consent to Release Information to Managed Care/Insurance Company was sent out to all Rehab After Work clinicians on January 18th, 2016 and will be utilized from that date moving forward, replacing the previous managed care consent form. All clients that were still engaged in treatment but started prior to January 18th, 2016 signed new updated consent forms, on or around January 18th, 2016.
The current Financial Responsibility Agreement & Authorization to Release Information to Insurance Company will be edited to utilize proper terminology and stay within the 4Pa. Code 255.5 regulation of confidentiality. The new Financial Responsibility Agreement & Authorization to Release Information to Insurance Company will be sent out to all Rehab After Work clinicians no later than March 15th, 2016 and will be utilized from that date moving forward, replacing the previous Financial Responsibility Agreement & Authorization to Release Information to Insurance Company. All clients that were still engaged in treatment but started prior to March 15, 2016 signed new Financial Responsibility Agreement & Authorization to Release Information to Insurance Company, on or around March 15th, 2016.
As per the discussion with Clinical and Regional Director at the time of the audit, Site Director pulled the Declaration of Custody and Consent to Therapy for any new adolescent starting treatment as of February 17, 2016 moving forward since it does not adhere to the state and federal regulations regarding minors seeking treatment. Clinicians were educated on the law regarding minors seeking counseling must be treated as the majority. The removal has taken place for all adolescent clients during the weekly staff meeting on February 17, 2016. All adolescents that were still engaged in treatment but started prior to February 17, 2016 with a custody agreement were made aware that this form has been void.
Site Director will perform quarterly audits of 10 charts minimum in order to monitor compliance with confidentiality regulations. Site director will perform these audits to ensure that the appropriate measures and documentation of confidentiality is being utilized in all consent forms on Rehab After Work paperwork, specifically stating the purpose for the release at hand.
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