Observations
Based on a review of client records, the project failed to document informed and voluntary consent to release forms that complied with Pa Code 255.5.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed
Ten client records were reviewed on February 5, 2016. The project failed to document informed and voluntary consent to release forms in client records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
1. The project has a "Managed Care/Insurance Company Authorization to Release Information Form" that all clients sign and agree to consent to release. The "Managed Care/Insurance Company Authorization to Release Information Form" is a project wide template form. The other box is checked off on this template form with the pretext "level of care evaluations, Authorizations, Status reports and Recommendations, Chart contents."
The release or documentation of the release of the client's "level of care evaluations and chart contents" does not comply with the stipulations of 255.5.
2. In addition, the project has a form titled "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company - The Light Program/Life Counseling Services/Rehab After Work," that was revised 10/15.
The form documents, "My signature below indicates my permission for The Light Program/Life Counseling Services/Rehab After Work to bill my insurance for payment. I give my permission to disclose information such as my diagnosis, my medication and dates I will be attending, as well as other pertinent information in order for my insurance company to grant authorization of my attendance."
The release or documentation of the release of the client's "medication and dates I will be attending as well as other pertinent information in order for my insurance company to grant authorization of my attendance" does not comply and exceeds the limitations imposed at 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.28 (c) Confidentiality
Site Director will conduct a training on Confidentiality with staff members during weekly staff meeting on 2/16/16. During this meeting, Site Director will review regulations and policies regarding client confidentiality, 4Pa. Code 255.5. Site Director will perform quarterly audits of 12 charts minimum in order to monitor compliance with confidentiality regulations. Site director will perform these audits to ensure that the appropriate measures and documentation of confidentiality is being utilized in all consent forms on Rehab After Work paperwork, specifically stating the purpose for the release at hand. The current managed care consent form will be edited to utilize proper terminology and stay within the 4Pa. Code 255.5 regulation of confidentiality. The new consent form was sent out to all Rehab After Work clinicians on January 18th, 2016 and will be utilized from that date moving forward, replacing the previous managed care consent form. All current active clients have signed this form and this form is placed in their charts. During staff meeting Site Director will review the importance of these forms continuing to be issued to all future clients. The Financial Responsibility Agreement & authorization to release information to insurance company forms have been corrected, are in all current active clients charts.
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