Observations
Based on a review of client records, the facility failed to obtain a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in four of sixteen client records.
The findings include:
Sixteen client records were reviewed on April 16 - 17, 2015. Sixteen client records were required to include documentation of written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client prior to disclosing information contained in the client record to a funding entity in client records # 5, 6, 7 and 9.
Client # 5 was admitted into treatment on August 7, 2014 and discharged on November 4, 2014. The facility failed to obtain a written, informed and voluntary consent from client # 5 prior to disclosing information contained in the client record to a funding entity.
Client # 6 was admitted into treatment on September 9, 2014. The facility failed to obtain a written, informed and voluntary consent from client # 6 prior to disclosing information contained in the client record to a funding entity.
Client # 7 was admitted into treatment on October 1, 2014. The facility failed to obtain a written, informed and voluntary consent from client # 7 prior to disclosing information contained in the client record to a funding entity.
Client # 9 was admitted into treatment on December 24, 2014. The facility failed to obtain a written, informed and voluntary consent from client # 9 prior to disclosing information contained in the client record to a funding entity.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 6 - 9, 2013 and April 17 - 18, 2014 licensing inspections.
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Plan of Correction
Facility will obtain appropriate Consents to Release Information for clients #5, 6, 7, and 9 where obtaining the consents are possible and remains relevant. The Clinical Supervisors will develop and provide a training update of the accurate and appropriate completion of consents to release information by May 15th, 2015 Information to be covered will include appropriate type of release, the appropriate release for funding sources, appropriate choice of information to be released; and limitations of 4 Pa. code subsection 255.5, at a minimum. Consents/Releases will be completed every time an individual's insurance changes at the time of the change. This will be completed by May 15th, 2015. Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and supervision. |