Observations
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 one of ten client records reviewed.
Client # 8 was admitted on October 16, 2019 and was still active at the time of the inspection. There was no documentation of the client being adjudicated dependent or delinquent or court ordered treatment, per Act 126 of 1998; however, the record contained a consent to release information form to a government agency, signed and dated by the client on October 19, 2019, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5, including the release of treatment plans, case consults and discharge summaries.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Client #8 did not have documentation of the client being adjudicated dependent or delinquent or court ordered treatment, per ACT 126 of 1998. Clinical supervisor will ensure that the correct consent forms are being signed by the client and that documentation of adjudicated dependent or delinquent or court ordered treatment is in the client file. This will be done through regular client file checks by the clinical supervisor to make certain this does not occur again. The clinical supervisor will ensure that staff are trained and supervised in proper consent forms being signed and making sure that documentation of adjudicated dependent or delinquent is present. Current client files will have proper documentation and consent and the training of all staff will be completed by 3-20-2020. |