Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record # 3. Additionally, the facility disclosed information prior to the patient signing an informed and voluntary consent to release form or beyond the limits of the signed consent form in client record #'s 1, 2, 3, 4, 5, 6, 8, 9, and 10.
Client #1 was admitted on 11/21/16 and was an active client at the time of inspection. The record contained a letter to an attorney, dated 12/7/16, released drug screen analysis results; however, the consent form, signed/dated 12/7/16, did not allow for the release of drug screen analysis results. Additionally, the record contained a prescription to the urinalysis lab for a drug screen analysis, dated 12/6/16, which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #2 was admitted on 3/25/16 and was discharged on 5/5/16. The record contained prescriptions to the urinalysis lab for drug screen analyses, dated 3/29/16, 4/6/16, 4/13/16, and 5/2/16, which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #3 was admitted on 4/29/16 and discharged on 6/8/16. The record contained documentation to the funding source, dated 5/10/16, 5/26/16, and 6/7/16, which released a list of medication and details client's personal history, which exceeded the limits established by 4 Pa. Code 255.5. Additionally, the record contained prescriptions to the urinalysis lab for drug screen analyses, dated 5/10/16, 5/26/16, and 6/7/16, which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure. Also, a letter to an attorney, dated 6/2/16, was documented in the record and it released drug screen analysis results; however, the consent form, signed and dated on 6/1/16, did not allow for the release of drug screen analysis results.
Client #4 was admitted on 6/22/16 and was discharged on 8/10/16. The record contained prescriptions to the urinalysis lab for drug screen analyses, dated 6/28/16, 7/5/16, 7/12/16, and 7/27/16, which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #5 was admitted on 8/30/16 and discharged on 10/20/16. The record contained prescriptions to the urinalysis lab for drug screen analyses, dated 8/31/16, 9/8/16, 9/13/16, 9/21/16, 9/28/16, and 10/3/16, which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client # 6 was admitted on 11/17/16 and was an active client at the time of the inspection. The record contained a prescription to the urinalysis lab for drug screen analysis, dated 12/6/16, which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #8 was admitted on 8/15/16 and was discharged on 9/28/16. The record contained prescriptions to the urinalysis lab for drug screen analyses, dated 8/23/16, 8/31/16, 9/8/16, 9/14/16, and 9/20/16, which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #9 was admitted on 5/18/16 and was discharged on 7/6/16. The record contained prescriptions to the urinalysis lab for drug screen analyses, dated 5/26/16, 6/1/16, and 6/13/16, which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
Client #10 was admitted on 10/21/16 and was discharged on 11/18/16. The record contained prescriptions to the urinalysis lab for drug screen analyses, dated 10/28/16 and 10/31/16, which identified the client's presence in treatment; however, there was no documented consent to release information form or Qualified Service Organization Agreement in place for the lab prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
a): Failure to have a QSO with Drug Screening Labs:
A Qualified Service Organization Agreement will be secured with the two drug labs used by the program. The Program Director will contact the labs and secure a signed mutual agreement no later than 2/15/2017.
Prior to execution of the QSO, all clients will sign an individualized release form for the appropriate Drug Screen Lab. This interim process will begin on 1/5/2017 for all new and active clients who have Lab testing. The completion of the releases, beginning on 1/5 and completed no later than 1/9, will be the responsibility of the Office Manager. The Clinical Supervisor will verify to the director by the end of the week that they have been completed. For all new clients, the Office Manager will include a release form specific to Drug testing in each of the new client intake paperwork packets. This too will be completed by 1/9/2017.
b): Sharing of information without specific consent:
The Clinical Supervisor, in weekly team supervision, will review with the team that any information that is released by letter or verbally must be detailed specifically on the release form. This reminder will be done in the Tuesday Supervision of 1/10/2017 and documented in the Supervision notes. The specific case that was cited by the DDAP reviewer (i.e. Attorney letter with drug screen results) will be used as an example to help the counselors understand how this applies.
Exceeding 4 Pa. Code 255.5 with insurance companies:
In some instances insurance companies request information that exceeds 4 Pa. Code 255.5. In Clinical Supervision Staff will be re-trained on how to communicate with insurance companies who seek information exceeding these regulations. This supervision will be conducted by the Clinical Supervisor and will occur on Tuesday 1/17/2017. It will be documented in the Clinical Supervision Notes. The Supervisor will hand out 4 PA Code 255.5 and discuss how it relates to insurances companies. We will discuss 255.5 (a) (7) which allows insurance companies an opportunity to apply for additional information.
Furthermore, as files are closed the Clinical supervisor will review the file to be sure that such a practice does not continue to occur. If identified in the file, the Clinical Supervisor will meet with the counselor and communicate the severity of this matter and establish through individual supervision training on this matter until it has been fully rectified.
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Observations
Based on a review of client records, the facility failed to include case consultation notes in client record #'s 2, 3, 4, and 10; therefore, a complete client record was not provided at the time of the inspection.
Client #2 was admitted on 3/25/16 and was discharged on 5/5/16.
Client #3 was admitted on 4/29/16 and discharged on 6/8/16.
Client #4 was admitted on 6/22/16 and was discharged on 8/10/16.
Client #10 was admitted on 10/21/16 and was discharged on 11/18/16.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy and Procedure has been revised to reflect that a Case Consultation will be done, at minimum, every 25 treatment days.
Additionally, the Clinical Supervisor has begun as of 12/20/2016 to document Case Consultations during weekly team supervision. This will allow for ample time to complete all Case Consultation in a timely fashion.
To be sure that this procedure continues, the file review of each closed case will verify that a Case Consultation has been completed in a timely fashion. This will be effective 1/11/2017. The Clinical Supervisor will be responsible to assure that at least one case conference will be completed on each client.
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