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 three of eleven records reviewed. Additionally, the facility failed to ensure that the release of information form was completed accurately in one of eleven records reviewed.
The findings included:
4 Pa. Code 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.
Eleven client records requiring proper releases of information were reviewed on October 5, 2015. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) specifically in client record #'s 4, 5, and 9. Additionally, the facility failed to ensure that the purpose of the disclosure was identified on the consent to release information form in client record #11.
Client #4 was admitted into treatment on December 3, 2014 and was still an active client at time of the inspection. A release of information form to the referral source, which was a government agency, was signed on 12/03/14 and allowed for the disclosure of the client's case consultation notes, which exceeded 255.5.
Client #5 was admitted into treatment on April 22, 2015 and was still an active client at time of the inspection. Two release of information forms to the same court system were signed on 4/22/15. One form allowed for the disclosure of the client's case consultation notes. The second form allowed for the disclosure of the client's urinalysis test results, history and physical, treatment plan goals and objectives, discharge summary, aftercare plan, and case consultation notes. Both consent to release forms exceeded 255.5.
Client #9 was admitted into treatment on November 24, 2014 and was discharged on April 7, 2015. A release of information to the insurance company was signed on 11/24/14 and allowed for the disclosure of the client's case consultation notes, which exceeded 255.5.
Client #11 was admitted into treatment on August 7, 2014 and was discharged on February 17, 2015. A release of information to the client's parent was signed and dated on 09/03/14; however; the release of information form did not include the specific purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An in-service training will be held with all staff members by 11/20/2015 reviewing all aspects of confidentiality including 4 Pa. Code255.5. This in-service will address what information may be released under 255.5 to government agencies, etc. as well as appropriate completion of releases. The Project Director will conduct the in-service. Releases in clients 4, 5 and 9 and 11's records will be reviewed if client is still active in treatment corrections to the releases will be made initialed, and dated by client and staff. The project director will ensure that these records are reviewed. |
Observations
Based on a review of client records, the facility failed to document a physician signature on the individual treatment plan updates for medical assistance clients in two of three client records reviewed.
The findings included:
Eleven client records were reviewed on October 5, 2015. Three of the client records were required to have a physician signature on the individual treatment plans and treatment plan updates. The facility failed to ensure that the doctor signed treatment plan updates in client records #2 and 7.
Client #2 was admitted into treatment on November 3, 2014 and was still an active client at the time of the inspection. Client #2 was identified as a Medical Assistance client. The physician failed to sign the 01/21/2015 treatment and rehabilitation plan update.
Client #7 was admitted into treatment on January 19, 2015 and was discharged on April 17, 2015. Client #7 was identified as a Medical Assistance client. The physician failed to sign the 01/30/2015 and the 03/25/2015 treatment and rehabilitation plan updates.
These findings were discussed with facility staff during the licensing process.
This is a repeat citation from the 10/23/2014 annual licensing renewal inspection.
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Plan of Correction
The agency by 11/16/15 will have an in-service with our medical director to review the need to sign each treatment plan. The agency will explore increasing the time on site of the medical director to ensure signatures on all treatment plans. The agency is moving towards an electronic health record in order to enable greater ease for the medical director and other staff to more efficiently manage items such as signing treatment plans by the medical director. Client records 2 and 7 will have treatment plan updates signed by medical director at his earliest convenience. This will be checked by the facility director and office manager. |