Observations
Based upon a review of the facility ' s consent to release information form titled
Release of Information (Revised August 2010), the facility failed to comply with state law 71 P.S federal regulation 42CFR Part 2, Subpart B, and 42CFR Part 2, Subpart C, findings include:
On January 18 through January 21, 2011 while reviewing client records, it was observed that the facility was using a consent to release information form titled Release of Information (Revised August 2010), the facility failed to comply with state law 71 P.S federal regulation 42CFR Part 2, Subpart B, and 42CFR Part 2, Subpart C, form did not comply for the following reasons:
The form allowed for the parent of a child to grant permission to release information. This is in violation of state law 71 P.S and federal regulation 42CFR Part 2, Subpart B, Regulation 42CFR Part 2, Subpart B, states:
Minor patients. (a) Definition of minor. As used in these regulations the term minor means a person who has not attained the age of majority specified in the applicable State law, or if no age of majority is specified in the applicable State law, the age of eighteen years. (b) State law not requiring parental consent to treatment. If a minor patient acting alone has the legal capacity under the applicable State law to apply for and obtain alcohol or drug abuse treatment, any written consent for disclosure authorized under subpart C of these regulations may be given only by the minor patient. This restriction includes, but is not limited to, any disclosure of patient identifying information to the parent or guardian of a minor patient for the purpose of obtaining financial reimbursement. These regulations do not prohibit a program from refusing to provide treatment until the minor patient consents to the disclosure necessary to obtain reimbursement, but refusal to provide treatment may be prohibited under a State or local law requiring the program to furnish the service irrespective of ability to pay.
State Law 71 P.S states:
Notwithstanding any other provisions of law, a minor who suffers from the use of a controlled or harmful substance may give consent to furnishing of medical care or counseling related to diagnosis or treatment. The consent of the parents or legal guardian of the minor shall not be necessary to authorize medical care of counseling related to such diagnosis or treatment. The consent of the minor shall be valid and binding as if the minor had achieved his majority. Such consent shall not be voidable nor subject to later disaffirmance because of minority. Any physician or any agency or organization operating a drug abuse program, who provides counseling to a minor who uses any controlled or harmful substance may, but shall not be obligated to inform the parents or legal guardian of any such minor as to the treatment given or needed.
The form failed to comply with federal regulation 42CFR Part 2, Subpart C, for the following reason:
The form required that the client sign or initial that they understood that there was a potential for the released information to be redisclosed by the recipient.
42CFR Part 2, Subpart C, states:
Prohibition on redisclosure.Notice to accompany disclosure. Each disclosure made with the patient's written consent must be accompanied by the following written statement: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.In addition the form includes the statement " I consent to release and disclosure of my confidential Drug & Alcohol related information " thus making it a general consent to release information.
The form also includes the statement " I consent to release and disclosure of my Confidential HIV-related information " . HIV related consents to release information are to be on a separate consent form.
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Plan of Correction
By March 23, 2011 our release of information form will be revised to read, "For mental health treatment only, print child's nameif under 14 years of age".
Effective March 23, 2011 the statement "I understand that there is a potential for the released information to be redisclosed by the recipient" will be deleted from our consent to release form.
By March 23, 2011 the statement "I consent to release and disclosure of my confidential HIV-related information" will be deleted from our release of information form.
By March 23, 2011 the statement "I consent to disclosure of my treatment summary,if any, in relation to my drug, alcohol abuse or dependency to medical personnel, government officials, judges and probation/parole officers and 3rd party payors. This is pursuant to 4Pa Code subchapter 255.5" will be deleted from our release of information form.
By March 23, 2011 the statement "I consent to release and disclosure of my confidential drug & alcohol related information" will be deleted from our release of information form.
The Director of Addictive Behavior Programs, the Vice-President of Behavioral Health and the President of JFK are responsible for making the above listed revisions to ensure compliance with drug/alcohol confidentiality regulations. |