INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2015 through February 20, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Montgomery County MH/MR Emergency Service, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of twelve records reviewed.
The findings included:
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.
Twelve client records requiring proper releases of information were reviewed on February 19, 2015 through February 20, 2015. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client record #'s 5, and 7.
Client #5 was admitted to treatment on February 12, 2015 and was still an active client at time of the inspection. A release of information to a government agency was signed on 02/13/2015 and allowed for the disclosure of the treatment plan, aftercare plan, discharge summary, and both verbal and written progress notes, which exceeded 255.5.
Client #7 was admitted to treatment on November 18, 2014 and was discharged on November 26, 2014. A release of information to an insurance company was signed on 11/19/2014 and allowed for the disclosure of the multi-disciplinary assessment, treatment plan, discharge orders, discharge information sheet, aftercare plan, discharge summary, and progress notes, which exceeded 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current Confidentiality Policy is being revised by the Medical Records Director to include the correction regarding the proper release of information to government agencies as identified in the record of client #5. As well, the confidential release form is being revised to reflection this correction.
Regarding client #7 ? An educational packet is being revised and reissued to all clinical staff that will include the proper information to be released to all agencies, including insurance companies. The packet will also include the updated Confidentiality Policy as well as sample completed release forms and the proper procedure for completing the release forms.
Monitoring will continue by Medical Records Director, Medical Records Staff, Performance Improvement Director, and Social Service Director of the release forms during monthly chart audits. Supervisors of staff who are not following the policies will be notified, and reeducation will be provided to the staff. If additional education is indicated, staff will be asked to attend the DDAP Confidentiality Course.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in two of twelve client records reviewed. Additionally, the facility failed to document a complete consent to release information, specifically the specific information to be released, in one of twelve client records reviewed.
The findings included:
Twelve client records requiring complete informed and voluntary consent to release information forms were reviewed on February 19, 2015 through February 20, 2015. The facility failed to ensure that an informed and voluntary consent to release information was obtained in client records #'s 3 and 4. Additionally, the facility failed to ensure that the specific information to be released was completed on the consent to release information form in client record #1.
Client #1 was admitted to treatment on February 12, 2015 and was still an active client at the time of the inspection. A release of information to another treatment provider was signed and dated on 02/13/2015; however; the release of information did not include the specific information to be released.
Client #3 was admitted to treatment on February 13, 2015 and was still an active client at time of the inspection. There was no signed/dated consent to release information form for the client's funding source documented in the client record at the time of review.
Client #4 was admitted to treatment on February 11, 2015 and was still an active client at time of the inspection. There was no signed/dated consent to release information form for the client's funding source documented in the client record at the time of review.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An educational packet is being revised and reissued to all clinical staff by the Medical Records Director that will include the proper information to be released to all agencies, including insurance companies. The packet will also include the updated confidentiality policy as well as sample completed release forms and the proper procedure for completing the release forms.
Monitoring will continue by Medical Records Director, Medical Records Staff, Performance Improvement Director, and Social Service Director of the release forms during monthly chart audits. Supervisors of staff who are not following the policies will be notified, and reeducation will be provided to the staff. If additional education is indicated, staff will be asked to attend the DDAP Confidentiality Course.
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