Observations
Based on a review of client records, 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 #'s 1, 2, 3, 4, 5, 6, 7, 8, and 9.
4 Pa. Code states that 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 the code, 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 into drug or alcohol abuse and the frequency of such relapse.
Client #1 was admitted on 09/02/2015 and was discharged on 03/07/2016. There were consent to release forms to two separate insurance companies, both dated 09/02/15, which allowed for the release of the discharge documentation, doctor ' s notes, HIV information, intake documentation, medication order sheets, psychiatric evaluation/CBE/CBR, therapist ' s notes, and treatment plans.
Client #2 was admitted on 02/09/2015 and was discharged on 05/06/2016. There was a consent to release form to the funding source, dated 03/10/16, which allowed for the release of the discharge documentation, intake documentation, medication order sheets, psychiatric evaluation/CBE/CBR, and treatment plans, as well as the consent form ' s expiration date for the consent form was 03/09/16. Additionally, a consent to release form to an insurance company, dated 3/10/16, which allowed for the release of the discharge documentation, intake documentation, medication order sheets, and psychiatric evaluation/CBE/CBR.
Client #3 was admitted on 02/25/2016 and was discharged on 06/17/2016. There was a consent to release form to the funding source, dated 02/25/16, which allowed for the release of the discharge documentation, doctor ' s notes, HIV information, intake documentation, medication order sheets, psychiatric evaluation/CBE/CBR, therapist ' s notes, and treatment plans. Additionally, there was a consent to release form to an insurance company, dated 02/25/16, which allowed for the release of the discharge documentation, doctor ' s notes, HIV information, medication order sheets, and psychiatric evaluation/CBE/CBR.
Client #4 was admitted on 11/23/2015 and was an active client as of the date of the inspection. There were consent to release forms to two separate insurance companies, both dated 11/23/15, which allowed for the release of the discharge documentation, doctor ' s notes, HIV information, intake documentation, medication order sheets, psychiatric evaluation/CBE/CBR, therapist ' s notes, and treatment plans.
Client #5 was admitted on 03/07/2016 and was an active client as of the date of the inspection. There were consent to release forms to two separate insurance companies, both dated 03/07/16, which allowed for the release of the discharge documentation, doctor ' s notes, HIV information, intake documentation, medication order sheets, psychiatric evaluation/CBE/CBR, therapist ' s notes, and treatment plans.
Client #6 was admitted on 11/26/2014 and was an active client as of the date of the inspection. There were consent to release forms to two separate insurance companies, both dated 12/03/15, which allowed for the release of the discharge documentation, medication order sheets, psychiatric evaluation/CBE/CBR, and treatment plans.
Client #7 was admitted on 07/29/2016 and was an active client as of the date of the inspection. There were consent to release forms to two separate insurance companies, both dated 07/29/16, which allowed for the release of the discharge documentation, doctor ' s notes, HIV information, intake documentation, medication order sheets, psychiatric evaluation/CBE/CBR, therapist ' s notes, and treatment plans.
Client #8 was admitted on 12/17/2015 and was discharged on 04/28/2016. There were consent to release forms to two separate insurance companies, both dated 12/17/15, which allowed for the release of the discharge documentation, doctor ' s notes, HIV information, intake documentation, medication order sheets, psychiatric evaluation/CBE/CBR, therapist ' s notes, and treatment plans.
Client #9 was admitted on 08/21/2015 and was discharged on 01/13/2016. There were consent to release forms to two separate insurance companies, both dated 09/02/15, which allowed for the release of the discharge documentation, doctor ' s notes, HIV information, intake documentation, psychiatric evaluation/CBE/CBR, therapist ' s notes, and treatment plans.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
the release of information form has been revised in order to comply with PA. code 255.5 release of information. The clinical Supervisor will provide 1 training on completion and utilization of the revised form. With regard to the deficient records reviewed during the inspection, each client who remains active since the inspection will sign the revised consent to release information form. We will also check this release in all other active records that were not reviewed during the inspection to ensure full compliance. the clinical supervisor will monitor staff completion of this form to ensure compliance. |