INITIAL COMMENTS
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This report is a result of a complaint investigation conducted by telephone on March 23, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Northern Tier Counseling, Inc., were substantiated. A plan of correction must be submitted by April 13, 2010.
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Plan of Correction
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709.26(c) LICENSURE Personnel Management
709.26. Personnel management.
(c) The project director shall develop written policies and procedures to provide for ongoing staff training and staff evaluation. Documentation shall include, but is not limited to:
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Observations
Based on the review of documentation; which included a list of client names and their diagnoses that was released by the facility to the Mental Health/Mental Retardation Administrator; and telephone interviews with the SCA Director and the Facility Director, the facility released client identifying information of twelve clients without the clients' informed and written consent to release that information.
The findings include:
A letter from the facility to the County Mental Health/Mental Retardation (MH/MR)Administrator dated December 5, 2009 included a list of clients in mental health treatment with the facility who were being terminated in 30 days from the date of the letter. A review of this list by the Single County Authority Director revealed that twelve of the clients on that list were enrolled in the drug and alcohol treatment activity. The list of client included the clients' diagnosis.
A phone interview with the Facility Director on March 23, 2010 confirmed that the names of the drug and alcohol treatment clients were inadvertently included with the list of mental health clients released to the MH/MR Administrator.
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Plan of Correction
The facility director has drafted a new policy to ensure that any client lists of names that are requested by the Mental Health County Administrator or his staff do not include drug and alcohol client names. This policy also states that the facility director or his/her assigned staff person will review all outgoing lists of mental health clients to make sure no primary diagnosed drug and alcohol clients are included. If drug and alcohol client lists are requested by the county MH/MR administrator then client names will only be released if said clients sign a release of information to do so. These changes have gone into effect as of the above listed date of 3/26/2010 to protect a clients privacy rights under State Law. |