Observations
Based on a review of client records, the facility failed to adhere to the limitations imposed under 4 Pa. Code 255.5 in four of ten records reviewed.The findings include:4 Pa. Code states: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 this section, 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.Ten client records were reviewed on December 10, 2015. The facility released information that exceeded the limitations imposed under 4 Pa. Code 255.5 in client records, # 2, 8, 9 and 10.Client #2 - Consent to release form dated November 10, 2015 for a government agency, allowed for the release of the following documents: the client's SS number, date of birth, address/phone number, Client #8 - Consent to release form dated May 21 , 2015 for a government agency, allowed for the release of the following documents: the client's SS number, date of birth, address/phone number, Client #9 - Consent to release form dated July 6, 2015 for a government agency, allowed for the release of the following documents: the client's SS number, date of birth, address/phone number, Client #10 - Consent to release form dated July 29, 2015 for a government agency, allowed for the release of the following documents: the client's SS number, date of birth, address/phone number, These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
L 0271 Confidentiality
(a) Daystar has a written policy to comply with 4 pa. Code 255.5.
A new release was developed by the executive director to address this compliance issue. The new release for the legal system and all it encompasses will only allow for disclosure of
1) Whether or not the client is or is not in treatment
2) Clients prognosis
3) Nature of project
4) Brief statement of progress
5) Short statement in regard to relapse or frequency of relapse.
This release has been implemented and a training for clinical staff will be held on 1/5/16, in order to educate the staff to the importance of disclosure to legal entities.
The Lead Counselor will ensure compliance to this policy and the Executive Director
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