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 seven of seven client records reviewed.
Patient #1 was admitted into the detoxification level of care on December 13, 2019 and was active at the time of inspection. A consent to release information form to the funding source, signed and dated by client, allowed for the release of psychiatric evaluations, history and physical, Doctors orders, Lab results and verbal treatment information, all which exceeded 255.5.
Patient #2 was admitted into the detoxification level of care on December 12, 2019 and was active at the time of inspection. A consent to release information form to the funding source, signed and dated by client, allowed for the release of psychiatric evaluations, history and physical, Doctors orders, Lab results and verbal treatment information, all which exceeded 255.5.
Patient #3 was admitted into the detoxification level of care on December 10, 2019 and was active at the time of inspection. A consent to release information form to the funding source, signed and dated by client, allowed for the release of psychiatric evaluations, history and physical, Doctors orders, Lab results and verbal treatment information, all which exceeded 255.5.
Patient #4 was admitted into the detoxification level of care on June 18, 2019 and was discharged June 26, 2019. A consent to release information form to the funding source, signed and dated by client, allowed for the release of psychiatric evaluations, history and physical, Doctors orders, Lab results and verbal treatment information, all which exceeded 255.5.
Patient #5 was admitted into the detoxification level of care on April 26, 2019 and was discharged May 10, 2019. A consent to release information form to the funding source, signed and dated by client, allowed for the release of psychiatric evaluations, history and physical, Doctors orders, Lab results and verbal treatment information, all which exceeded 255.5.
Patient #6 was admitted into the detoxification level of care on May 24, 2019 and was discharged May 30, 2019. A consent to release information form to the funding source, signed and dated by client, allowed for the release of psychiatric evaluations, history and physical, Doctors orders, Lab results and verbal treatment information, all which exceeded 255.5.
Patient #7 was admitted on into the detoxification level of care on October 17, 2019 and was discharged October 23, 2019. A consent to release information form to the funding source, signed and dated by client, allowed for the release of psychiatric evaluations, history and physical, Doctors orders, Lab results and verbal treatment information, all which exceeded 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Release of Information form for the funding source was revised to reflect the limits on disclosure of client identifying information established in 4 PA Code 255.5.
A memo was sent to Social Services and Access Center staff as well as Nursing leadership on 1/10/20 informing them of the revised Release of Information to the funding source. The form will be implemented by 1/15/20.
The Director of Social Services or designee will audit 25 charts per month to ensure that releases of client identifying information to funding sources remains within the limits established in 4 PA Code 255.5. Audits will continue until 100% compliance is achieved for 3 consecutive months. Audit results will be reviewed monthly in the Quality Council Meeting.
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