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 client record # 2.
Client #2 was admitted on March 22, 2018 and was an active client as of the date of the inspection. A consent to release form was signed and dated on March 22, 2018 to the a government agency that allowed for the release of the aftercare treatment plan, discharge summary, treatment plans, psych eval, and medical history.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Facility Director will oversee that all staff are re-educated to complete consent to release forms in accordance with 4 Pa. Code 255.5. The consent to release form for Client #2 was voided. The Quality Improvement Department will ensure ongoing compliance via random chart audits. |