INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 8, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management, Inc., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to document a confidentiality policy and procedure compliant with 4 Pa. Code subsection 255.5.
The findings included:
4 Pa. Code subsection 255.5 (a)(6), states: "Projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client; or, to a prospective employer who affirmatively expresses 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."
The facility policy and procedure manual was reviewed as part of the annual onsite licensing inspection of March 5 - 6, 2012. Policy # 60,006, section C, subsection 2, letter f, exceeded 4 Pa. Code subsection 255.5 (a)(6), as it allowed for the following: "Life Management may disclose with the client's consent, the information to employers of a client to further the client's rehabilitation; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Information released shall be limited to that provided for in subsection 4.a. in this section."
Subsection 4.a. states: " Nature of Client Information to be Disclosed. a. Information released to judges, probation or parole officers, insurance company, health or hospital plan or government officials, pursuant to section C.2.a-i of this section, is for the purpose of determining the advisability of continuing th client in treatment with Life Management and shall be restricted to the following:
i. Whether or not the client isn't in therapy
ii. The prognosis of the client
iii. The nature of the project
iv. A brief description of the client's progress
v. A short statement as to whether the client has relapsed into drug or alcohol abuse and the
frequency of such relapse."
The project's Confidentiality policy permits for the release of information under ii, iv, and v, which is restricted under 4 PA Code 255.5(a)(6).
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Plan of Correction
The Executive Director of Rehab After Work will change the policy and procedures section in our manuel (#66006) to reflect the "information specifically released to employers will be limited to whether a client has or is receiving treatment with the project". This will be circulated to all offices. All staff were required to attend a 6 hour training on Confidentially (255.5) held on 4-13-12 and presented at the Phoenixville location. This policy addendum was reviewed by all satff at the training. Site directors will perform random, monthly chart audits to ensure that this policy change is being reflected by all clinicians. |
709.28(c)(2) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based upon a review of client records, the facility failed to follow 4 PA Code 255.5(a)(6) regarding release of information to employers in that it released too much information to a client's employer.
The findings include:
Eight client records were reviewed for compliance with 4 PA Code 255.5(a)(1-10) and (b)on March 8, 2012. One of eight records, specifically record # 4, exceeded 4 PA Code 255.5(a)(6). Record # 6 contained a letter addressed to the client's employer that included the following disclosure:
"This is to verify that the above-mentioned client completed our Intensive Outpatient Treatment Program effective November 4, 2011.
Redacted client name attended every session, four times per week, and was a full participant. He followed all suggestions, and all of his drug screenings were 'negative.'"
The facility's release of information regarding participation level and drug screening results exceeded 4 Pa. Code, subsection 255.5 (a)(6), as it states: "Projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client; or, to a prospective employer who affirmatively expresses 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."
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
The site director of the Havertown Location of Rehab After Work held a one hour training regarding the limitations of disclosure to an employer or prospective employer. "The information released shall be limited to that provided in 4 PA Code subsection 255.5 (a) (6). This training took place on 4-4-12 and all staff signed off that they attended, understood the limitations of the disclosure and will follow the direction given. |