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 client record #4
Client number four was admitted on 3/9/18 and was discharged on 8/16/18. A consent to release information form was signed and dated on 4/18/18 to the probation office that allowed for the release of admission/discharge summaries, psych evaluations, Goal/Treatment plans, psychological reports, progress notes and medication/medical data.
The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Clinical staff selected the wrong type of release of information for client #4, a release from a primary care physician, when they should have selected a D&A release to their probation officer. On 4/18/18 clinical supervisor added the correct release of information to the client's probation officer, signed by the client to the record of client #4. The incorrect release was end dated 4/19/18 on 9/17/18 by the Director of Substance Abuse Services, thus preventing confidential information from being disclosed in the future. Clinical Supervisor has reviewed confidentiality with all clinical staff during individual and group supervision. Clinical supervisor will review client charts and confidentiality with clinical staff during supervision weekly. Clinical staff will attend additional confidentiality training as needed. The facility will be in full compliance 10/1/2018. |