Observations
Based on a review of client records, the facility failed to comply with the restrictions imposed at 4 Pa. Code 255.5 (b)(1-5) in six of six client records reviewed.
The findings included:
4 Pa. Code 255.5 (b)(1) includes the following language:
Restrictions. Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), 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) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Nine client records were reviewed on February 3-4, 2014. Six client records were reviewed regarding documentation of consent to release client information forms. The facility failed to comply with the restrictions imposed at 4 Pa. Code 255.5 (b)(1-5) in client records # 1, 2, 3, 4, 5 and 6.
Client #1 was admitted to treatment on September 5, 2013. A consent to release client information form, for the client's funding source, was signed by the client on September 5, 2013. The facility failed to comply with the restrictions imposed at Pa Code 255.5 (b)(1-5) as the information to be released to the funding source included the 'potential benefit for treatment, support services utilized, counselor recommendations and attendance patterns.'
Client #2 was admitted to treatment on September 30, 2013. A consent to release client information form, for the client's funding source, was signed by the client on September 30, 2013. The facility failed to comply with the restrictions imposed at Pa Code 255.5 (b)(1-5) as the information to be released to the funding source included the 'potential benefit for treatment, support services utilized, counselor recommendations and attendance patterns.'
Client #3 was admitted to treatment on October 8, 2013. A consent to release client information form, for the client's funding source, was signed by the client on October 8, 2013. The facility failed to comply with the restrictions imposed at Pa Code 255.5 (b)(1-5) as the information to be released to the funding source included the 'potential benefit for treatment, support services utilized, counselor recommendations and attendance patterns.'
Client #4 was admitted to treatment on January 8, 2014. A consent to release client information form, for the client's funding source, was signed by the client on January 8, 2014. The facility failed to comply with the restrictions imposed at Pa Code 255.5 (b)(1-5) as the information to be released to the funding source included the 'potential benefit for treatment, support services utilized, counselor recommendations and attendance patterns.'
Client #5 was admitted to treatment on November 11, 2013. A consent to release client information form, for the client's funding source, was signed by the client on November 11, 2013. The facility failed to comply with the restrictions imposed at Pa Code 255.5 (b)(1-5) as the information to be released to the funding source included the 'potential benefit for treatment, support services utilized, counselor recommendations and attendance patterns.'
Client #6 was admitted to treatment on June 20, 2013. A consent to release client information form, for the client's funding source, was signed by the client on June 20, 2013. The facility failed to comply with the restrictions imposed at Pa Code 255.5 (b)(1-5) as the information to be released to the funding source included the 'potential benefit for treatment, support services utilized, counselor recommendations and attendance patterns.'
The findings were reviewed with the facility director and clinical supervisor.
|
Plan of Correction
The clinical director will review with the clinical supervisors and counselors, regulations in regards to release of information. The Clinical Supervisor will ensure that the release of information only include the following information to be released:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
All clients admitted as of 2-14-14 will have correct release of information's in record. |