Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that limited specific information disclosed to the parameters outlined at 4 Pa. Code subsection 255.5(b) in three of six client records. The findings include:Six client records were reviewed on November 20, 2008. Six client records were required to include informed and voluntary consents to release information from the client for the disclosure of information contained in the client record. The facility failed to obtain an informed and voluntary consent that limited specific information disclosed to the parameters outlined at 4 Pa. Code subsection 255.5(b) in client records #2, 3 and 4. Specific information disclosed to the insurance company in client records #2, 3 and 4 included treatment plans, case consults and discharge summaries.
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Plan of Correction
All clients that receives funding from an insurance entity (Magellan) sign a release of information specific to that entity. The releases that were voluntarily signed by clients did not specifically limit treatment information to be released. The executive director will ensure that staff are trained and supervised to limit the information to be released to Magellan. Training of all staff will be completed by Jan. 15, 2009, at this time all records will have informational specifically released on the forms. |