Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in two of eight 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.
Eight client records were reviewed on March 22, 2016. All were reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in client records, # 1, 2, 5, 6 and 8.
Client #3 - Consent to release dated December 14, 2015, for an insurance company, failed to adhere to the limitations imposed under 4 PA. Code 255.5. The facility checked the box medications.
Client #5 - Consent to release dated October 29, 2015, for an insurance company, failed to adhere to the limitations imposed under 4 PA. Code 255.5. The facility checked the box medications.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will ensure the implementation of these service changes.
-Approved in-house DDAP staff training: Confidentiality Training 4/16/16
- 2 consent forms will be created; the first consent will be specific to those entities restricted to the 5-points under Pa. Code. The second consent will be specific to third party consents.
-The consents for those clients who were included in the audit (client # 1, who is still a resident) will be updated by 6/13/16.
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