Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in nine of eighteen client records.
The findings include:
Eighteen client records were reviewed for written, informed and voluntary consents to release information from the client on March 30 - April 1, 2016. The facility failed to obtain an informed and voluntary consent to release information from the client in client records # 1, 4, 5, 6, 10, 11, 12, 13 and 15.
Based on a review of these records, the facility's consent to release client information form was out of compliance with 42 CFR and State Law 4 Pa. Code 255.5.
The facility's consent to release client information form is a standardized form titled "Authorization to Disclose Healthcare Information". The consent form included the following statement: "I may revoke this authorization at any time. Revocations to this authorization must be in writing". 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release information form can be revoked by the client at any time and there is no restriction on the manner in which the client may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the client to revoke the consent to release information in writing.
Client # 1 was admitted into treatment on March 26, 2016. Consent to release information forms for the funding entity and family member were signed by client # 1 on March 26, 2016. The facility failed to adhere to the requirements in 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) by restricting the client to a written revocation of the consent to release information form. In addition, the facility allowed for the release of the client's alcohol, drug or substance abuse and mental health records to the funding entity. This exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 4 was admitted into treatment on February 25, 2016 and discharged on March 1, 2016. Consent to release information forms for the funding entity, treatment provider and family member were signed by client # 4 on February 25, 2016. The facility failed to adhere to the requirements in 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) by restricting the client to a written revocation of the consent to release information form. In addition, the facility allowed for the release of the client's alcohol, drug or substance abuse and mental health records to the funding entity. This exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 5 was admitted into treatment on February 28, 2016. A consent to release information form for a social service provider was signed by client # 5 on March 25, 2016. The facility failed to adhere to the requirements in 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) by restricting the client to a written revocation of the consent to release information form.
Client # 6 was admitted into treatment on February 11, 2016. A consent to release information form for a family member was signed by client # 6 on March 14, 2016. The facility failed to adhere to the requirements in 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) by restricting the client to a written revocation of the consent to release information form.
Client # 10 was admitted into treatment on February 26, 2016. Consent to release information forms for the funding entity, physician and family member were signed by client # 10 on February 26, 2016. The facility failed to adhere to the requirements in 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) by restricting the client to a written revocation of the consent to release information form. In addition, the facility allowed for the release of the client's alcohol, drug or substance abuse and mental health records to the funding entity. This exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 11 was admitted into treatment on March 1, 2016. Consent to release information forms for the funding entity, physician, treatment provider and family member were signed by client # 11 on March 1, 2016. The facility failed to adhere to the requirements in 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) by restricting the client to a written revocation of the consent to release information form. In addition, the facility allowed for the release of the client's alcohol, drug or substance abuse and mental health records to the funding entity. This exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 12 was admitted into treatment on March 1, 2016 and discharged on March 31, 2016. Consent to release information forms for the funding entity, probation officer, treatment provider and family member were signed by client # 12 on March 26, 2016. The facility failed to adhere to the requirements in 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) by restricting the client to a written revocation of the consent to release information form. In addition, the facility allowed for the release of the client's alcohol, drug or substance abuse and mental health records to the funding entity and probation officer. This exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 13 was admitted into treatment on March 9, 2016. Consent to release information forms for the funding entity, government agency and family member were signed by client # 13 on March 9, 2016. The facility failed to adhere to the requirements in 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) by restricting the client to a written revocation of the consent to release information form. In addition, the facility allowed for the release of the client's alcohol, drug or substance abuse and mental health records to the funding entity and government agency. This exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 15 was admitted into treatment on January 29, 2016 and discharged on February 16, 2016. A consent to release information form for a treatment provider was signed by client # 15 on February 12, 2016. The facility failed to adhere to the requirements in 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) by restricting the client to a written revocation of the consent to release information form.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Records Coordinator will provide training on the proper documentation for the release of information on the consents. Staff will be directed to write "consent may be revoked verbally" on all consents. The consent to release information will be compliant with 42 CFR and 4 Pa. Code 255.5. The Medical Records Coordinator will randomly check 5 charts per week for the next 8 weeks to ensure consents are correct. The corrective action date for this to occur will be June 30, 2016. The Quality Director and Regional Vice President are working with Corporate to assure the current consents are 255.5 compliant. |