Observations
Based on a review of client records and an interview with the project director and one of the clinical supervisors, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information, or released information that exceeded that which is permissible under 4 Pa. Code subsections 255.5 (b), in 14 out of 19 client records reviewed.
The findings include:
From January 20, 2011 through January 21, 2011, nineteen records were reviewed for consent to release information forms. The facility released information without the clients' consent, or released information that exceeded what is permitted under 4 Pa. Code subsections 255.5 (b), in 14 out of 19 client records reviewed.
Client records # 3, 9, 10, 12, 19 & 20 contained letters to government agencies, releasing client information, but the facility did not document a signed consent from the client to release the information.
Client records # 17, 18, 19, 20, 21, and 25 contained consent to release information forms that exceeded what the facility is allowed to release to government agencies and insurance companies under 4 Pa. Code subsections 255.5 (b). In client records # 17, 18, 19, 20, 21, and 25 the facility documented the release of discharge summary, aftercare plans, treatment plans, medical history, drug and alcohol history, and/or financial information to government agencies.
In client records # 1, 3, 5, 6, 10, and 14 the facility documented the release of client information to government agencies that exceeded 4 Pa. Code subsection 255.5 (b).
In client records # 9 and 12 the facility documented the release of client information to government agencies that exceeded 4 Pa. Code subsection 255.5 (b). The facility released the clients' treatment history.
In client records # 18 and 21 the facility documented the release of client information to insurance companies that exceeded 4 Pa. Code subsection 255.5 (b). The facility documented the release of treatment plans, discharge summary, aftercare plans, medical history, drug and alcohol history, and/or financial information.
Client record # 19 contained a letter to a county probation office, releasing the recommendation that the facility had given to the client. However, the facility did not document a signed consent from the client to release the information.
Client record # 20 contained a letter to government agencies, releasing the recommendations that the facility had given to the client. However, the facility did not document a signed consent from the client to release the information.
An interview with the project director and one of the clinical supervisors on January 21, 2011 confirmed that the facility included information in the client records mentioned above that exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (b) and/or released information to agencies without a signed consent from the client.
In addition, based on a review of client records and an interview with the project director and one of the clinical supervisors, the facility failed to develop and maintain standardized consent to release information forms that were consistent with state regulations at 28 Pa. Code subsection 709.28 (c) regarding an informed consent.
Client records # 1, 2, 3, and 5 of the partial hospitalization activity and client records # 6, 7, 9, 10, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 27 of the outpatient activity contained consent to release information forms which included the language
"Release/Request" on both the heading of the form as well as in the text of the document. Drug and Alcohol regulations make no provision for requesting information or exchanging information with other persons or entities. Only releases of information are addressed. (Reference: Act 63 P.S.(b)1690.108 ; 42 CFR Part 2, Subpart A, subsection 2.2(a); and 4 Pa. Code subsection 255.5(a)).
An interview with the project director and one of the clinical supervisors on January 21, 2011 confirmed that the consent to release information forms which included " Release/Request " on both the heading of the forms as well as including this language in the text of the document were in client records # 1, 2, 3, and 5 of the partial hospitalization activity and client records # 6, 7, 9, 10, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, and 27 of the outpatient activity.
|
Plan of Correction
The Clinical Director and all Clinical Supervisors shall facilitate an in-house training on Confidentiality on March 25, 2011. The training solely will be focused on Confidentiality and will address all areas outlined in the attached citation and licensing standard 709.28. The Supervisory staff will focus on this area in our quartery casefile reviews and the traing will be repeated semi-annually during a staff meeting. New hires will receive the training within 30 days of employment at the Agency.Some of the confusion centered on information released to the County Case Mangement Unit: the Director vs. Case managers. Thanks to the Licensing Specialist this is better understood by management and already has been relayed to all clinical staff but will be presented as part of the training.
The form itself will be modified to read "Release" only. "Request" will be deleted. |