Observations
Based on a review of the client chart, the facility failed to obtain client consent to disclose information contained in the client record. Based on a review of the client's chart, a signed consent form was not observed to allow for the client information that was released in November 2020 by facility staff to the court evaluator/psychiatrist under Pa code 255.5.
|
Plan of Correction
The deficiency will be corrected by reviewing any consent form to disclose information for each of the elements below. If the form is missing even one of the elements, it shall not be considered a valid consent. Therefore, the information shall not be released.
Every consent to disclose shall be signed and dated by the client. The form shall specify the exact purpose of the disclosure.
The facility is required to adhere to the Rule (Title 42 CFR Part 2 ? Confidentiality of Alcohol and Drug Abuse Patient Records). In order for the facility to disclose any information about a client, the client must authorize the disclosure by signing a valid consent form. The consent form must contain all of the following nine elements to be valid:
1. The name of the client.
2. The name of the program making the disclosure.
3. The recipient of the information (which should not be as general as an entire agency or department, but may describe the recipient's job title and/or job functions).
4. The purpose of the disclosure, which should be narrowly described and should correspond with the information to be released.
5. The information to be released, described as exactly and narrowly as possible.
6. That the client understand the consent maybe revoked at any time, orally or in writing.
7. The date or condition upon which the consent expires, if it has not been revoked earlier.
8. The date the consent form is signed.
9. The signature of the client.
A client should never sign or be requested to sign a consent form before all of the blanks have been filled in. Copies of all consent forms shall be kept in the client's file. Clients will be offered a copy of all consent forms and an acknowledgement of same will be on every consent form.
The Project Director will review the Confidentiality Policies and Procedures with all treatment staff by May 15, 2021.
The Project Director, with the Quality Assurance Committee, will review 100% of the records of new admissions on a monthly basis, to verify and report any problems to the supervisors of responsible staff for correction.
The effectiveness of these measures will be evaluated by the Quality Assurance Committee at each meeting and modified as necessary. |