Observations
Based on a review of two unusual incident reports received by the Department on August 3, 2022, the facility failed to obtain an informed and voluntary consent from clients prior to giving identifying information to someone.
There was no documentation of an informed and voluntary consent to release information to a law enforcement body.
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Plan of Correction
In response to this incident, an email was sent out on 8/3/22 by the Assistant Director to all Program Monitor Staff titled "AMA Procedure" to detail proper protocol in the event of an AMA. In addition, Firetree's Confidentiality Policy is reviewed with all current staff annually during our Confidentiality and HIPPA training held in November of each calendar year. New employees are required to complete a training, Hippa Basics, within the first two weeks of employment. New employees are also required to review to reviewing all of Firetree's policies, including the attached Confidentiality Policy, within their first two weeks of employment. Please see the attached Confidentiality Policy for reference. This policy is also available for viewing by all employees on our training website.
Policy and Procedures Manual
Authority: Medical Director
Policy #: 7-010D
Effective Date: 7/29/01
Revision Date(s): 5/07/04, 06/23/14
Subject: Confidentiality/General Policy on Confidentiality of Client Identity and Records
Policy:
Drug and Alcohol Treatment Programs demonstrate adherence to federal and state confidentiality laws and regulations with regard to client identity, client records, and staff access to client records. Confidentiality of client identity and client records is maintained for every client and every client record in accordance to applicable federal and state laws and regulations, including but not limited to 42 CFR Part 2 (regarding Confidentiality of Alcohol and Drug Abuse Patient Records), 45 CFR Part 164, Subpart E (regarding Privacy and Individually Identifiable Health Information), 28 Pa. Code Section 709.28 (regarding Confidentiality), and 4 Pa. Code Section 255.5 (regarding Disclosure of Client-Orientated Information).
Applicable procedures have been developed to protect the agency and affiliated organizations from liability, protect the client from the possibility of exposure to stigma.
This general policy on confidentiality is supplemented by the organization's policies and procedures regarding: Confidentiality/ Staff Access to Records; Confidentiality/ HIV Related Information; Confidentiality/ Client Access to Records; Confidentiality/ Security of Client's Records; Confidentiality/ Informed and Voluntary Consent; Confidentiality/ Release of Information without Client Consent; and Confidentiality/ Reporting Suspected Child Abuse. If any of these policies contradict this general client confidentiality policy, the policy that is more protective of client confidentiality shall apply.
Scope:
This general policy on confidentiality is applicable to all staff that comes into contact with information about individuals receiving, having received, or having applied to receive substance abuse treatment.
It also applies to the following individuals:
§ Holder: an individual or program in possession of such information may not release it except as authorized by the patient or as otherwise permitted by the regulations.
§ Seeker: anyone seeing information may not compel its disclosure except as permitted by the regulations.
§ Receiver: anyone who receives such information may not redisclose it without patient consent or as otherwise authorized by the regulations.
The primary counselors shall maintain client files. The Facility Director and Clinical Director shall monitor compliance with this policy by all staff under their control.
Procedure:
1. Information systems and reporting systems shall not disclose client oriented data which reasonably may be utilized to identify the client to any person, agency, institution, government unit, or law enforcement personnel. Project staff may disclose client oriented data, with the consent of the client, only under the following situations:
a. With the consent of the client, information may be released to those judges who have imposed sentence on a particular client where such sentence is conditioned upon the client entering a project. Information released shall be limited to that as identified in (i) below.
b. With the consent of the client, information may be released to those duly authorized probation or parole officers who have assigned responsibility to clients in treatment if the client's probation or parole is conditioned upon being in treatment. Information released shall be limited to that as identified in (i) below.
c. With the consent of the client, information may be released to judges who have assigned a client to a project under a pre-sentence, conditional release program. Pre-sentence conditional release programs include pre-indictment or pre-conviction conditional release (such as ARD), probation without verdict or disposition in lieu of trial pursuant to section 17 and 18 of Act 64 (35 P.S. paragraphs 780-117 and 780-118).
d. With the consent on the client, information may be released to a judge in order to assist that judge in deciding whether to initiate conditional release programs including those specified in (c) above.
e. With the consent of the client, information may be released to employers of the client to further the rehabilitation of the client. Information may also be released to prospective employers who affirmatively express that information is sought to enable the employer to engage the client as an employee. Such information shall be limited to whether the client has or is receiving treatment with the project.
f. With the consent of the client, information may be released to the client's attorney if the attorney is representing the client in a criminal, civil, or administrative proceeding.
g. With the consent of the client, information may be released to an insurance company, health, or hospital plan or facsimile thereof, which has contracted with the client to provide or will provide medical, hospital, disability, or similar benefits. Information released shall be limited to that as identified in (i) below.
h. With the consent of the client, information may be released to governmental officials for the purpose of obtaining governmental benefits due the client as a result of the client's drug or alcohol abuse or dependence. Information released shall be limited to that as identified in (i) below.
i. Information released to judges, probation or parole officers, insurance companies, health or hospital plans, or government officials for the purpose of determining the advisability of continuing the client with the assigned project shall be restricted to the following information:
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.
2. The project will keep and maintain a written record of all client-oriented information and data that is disclosed.
3. The Client Admission forms, Treatment/Discharge forms, and Discharge Summary Records are the only client records that may be transferred for treatment purposes. Such forms/records may only be transferred with the written consent of the client after the client is informed of and fully understands the nature of the information, the purpose of the record transfer, and the identity of the recipient of the forms/records.
4. For client-oriented data sought without client consent, including emergency medical situations where the life of the client is in immediate jeopardy, staff shall refer to and comply with the program's policy regarding Confidentiality/Release of Information with Client Consent (709.28(e)(1,2).
5. Staff are expected to strictly adhere to all confidentiality requirements. A breach of confidentiality is considered a serious violation of policy. Written reprimands, suspensions without pay, demotion, and termination are forms of disciplinary actions that the governing body implements for employee infractions that are considered a serious detriment to operations or are repetitive. Employee disciplinary actions are made part of the staff's personnel record and include a written narrative of the specific violation, disposition imposed, effective date of the discipline, any appeal actions, and progressive consequences for reoccurrence.
Standard: 709.28(a)
Cross-Reference to Standard:
ACA: 4-ACRS-4C-19, 4-ACRS-6A-04
PA Depart of Health: Confidentiality/ Staff Access to Records 709.28 (a)(2); Confidentiality/ HIV Related Information; Confidentiality/ Client Access to Records 709.30 (3); Confidentiality/ Security of Client's Records 709.28 (b); Confidentiality/ Informed and Voluntary Consent 709.28 (c) (1,2,3,4,5,6), 709.28 (d); Confidentiality/ Release of Information without Client Consent 709.28(e)(1,2); and Confidentiality/ Reporting Suspected Child Abuse 709.28 (e)(2)
JCAHO: RI.2.30, RI.2.40, RI.2.130
DPW: None
Cross-referenced Policy: #7-020, #10-050, #10-051, #6-080, #7-021D
Superseded Standard: (ACA 3-ACRS-1C-17, 1E-06 to 1E-08, 4E-24), RI.1, RI.1.5, RI.1.5, RI.2.2, IM.2, IM.7.2.10, RI.1.2.2, DPW: 5100.55, HIPAA 1996, Public Law 104 - 191
Supporting Documentation: consent forms, Consent to Obtain Confidential Information
Related Forms: Client Contract & Consent to Participate (form # 20), Orientation and Consent to Treatment (form # 73), medical consent forms, Consent to Release (form #32)
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