Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release information form from the client prior to the disclosure of information in six of ten client records.
The findings include:
Ten client records were reviewed on May 8, 2013. Ten client records were required to include an informed and voluntary consent form from the client prior to the disclosure of information.
Client record #1 - The client was admitted on 1-28-2013, and was discharged on 3-15-2013. There was a release of information signed on 2-11-2013, that does not include the name of the person, agency, or organization to whom disclosure is made, and does not include the specific information to be disclosed. Another release of information for an emergency contact was signed on 2-11-2013 and does not indicate the specific information and the purpose of the disclosure.
Client record #2 - The client was admitted on 3-21-2013. Release of information forms for an emergency contact, a funding source and a laboratory all signed on 3-20-2013, were incorrectly completed. On all three release forms, all of the options were indicated for the specific information section and the purpose section. In addition to not being correctly completed, this exceeds the limitations on information to be disclosed to the funding source.
Client record #5 - The client was admitted on 2-4-2013, and discharged on 4-22-2013. A release of information form to another provider was signed on 3-20-2013. The release of information form does not indicate "release to" , but indicated "obtain from" on the form.
Client record #8 - The client was admitted on 3-21-2013. The release of information to the probation office was signed on 2-28-2013, but failed to indicate "release to". A release of information to a funding source signed on 2-28-2013 did not list the specific information to be disclosed.
Client record #9 - The client was admitted on 4-18-2013. The consent to release information form for the funding source was signed on 4-3-2013. The information listed exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b).
Client record #10 - The client was admitted on 4-11-2013. The release of information form for the laboratory signed on 3-27-2013 did not list the specific information to be disclosed.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
Facility will obtain appropriate Consents to Release Information for clients #1,2,5,8,9,10 where obtaining the consents is possible and remains relevant. The Clinical Supervisors will develop a training update of the accurate and appropriate completion of consents to release information by June 30, 2013 and present the training to all staff during July 2013 staff meetings and clinical supervision, both group and individual. Information to be covered will include appropriate purpose; specific purpose; appropriate choice of information to be released; limitations of 4 Pa. code subsection 255.5, at a minimum.
It shall be the responsibility of the Clinical Supervisors to ensure ongoing compliance with this regulation through record reviews and clinical supervision.
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