Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in three of ten client records reviewed.
The findings include:
Ten client records were reviewed on November 4-5, 2014. All ten client records were required to obtain an informed and voluntary consent from the client for the disclosure of information.
Record #3 - Client was admitted to treatment on 2-12-2014, and was discharged on 7-29-2014. A parent signed the witness signature line on six forms included in the client record. Forms including the consent to treatment, client access to records, and release of information forms for funding sources and the probation office were signed on 2-12-2014. A release of information form for the parent was not signed until 4-17-2014.
Record #7 - Client was admitted to treatment on 8-8-2014. A release of information was signed on 8-8-2014, but specific information to be disclosed and the purpose of the disclosure were blank.
Record #10 - Client was admitted to treatment on 7-21-2014. A letter dated 10-8-2014 was sent to a Medical Center, but there was no documentation of a release of information signed by the client permitting the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will re-educate staff on PA regulation 711.93 regarding confidentiality and the release of information forms. The facility director will continue to perform open chart audits to ensure compliance with this regulation. |