Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in eleven of twelve client records.
The findings include:
4 Pa. Code 255.5 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
Twelve client records were reviewed on April 4, 2016. The facility's consent to release was observed to be out of compliance with 42 CFR and State Law 4 Code 255.5 (b) in client records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11.
In addition, the "Authorization for Release of Information" form did not contain documentation of the client's right to verbally revoke a signed consent for the release of information. The facility's "Authorization for Release of Information" form documented, "I may revoke this authorization at any time. Revocations to this authorization must be presented in writing."
Client #1 was admitted on March 31, 2016 and was still an active client at the time of inspection. On a consent form dated 3/31/16, the facility allowed for the release of the client's alcohol, drug, or substance abuse records and mental health records to probation thus exceeded the limitations imposed at 4 Pa code 255.5(b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke the consent in writing.
Client #2 was admitted on March 31, 2016 and was still an active client at the time of inspection. On a consent form dated 3/31/16, the facility allowed for the release of the client's alcohol, drug, or substance abuse records and mental health records to an insurance company thus exceeded the limitations imposed at 4 Pa code 255.5(b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing.
Client #3 was admitted on April 2, 2016 and was still an active client at the time of inspection. On a consent form dated 4/2/16, the facility allowed for the release of the client's alcohol, drug, or substance abuse records and mental health records to an insurance company thus exceeded the limitations imposed at 4 Pa code 255.5(b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing.
Client #4 was admitted on February 20, 2016 and discharged on February 25, 2016. On a consent form dated 2/20/16, the facility allowed for the release of the client's alcohol, drug, or substance abuse records and mental health records to an insurance company thus exceeded the limitations imposed at 4 Pa code 255.5(b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing.
Client #5 was admitted on January 13, 2016 and discharged on January 18, 2016. On a consent form dated 1/13/16, the facility allowed for the release of the client's alcohol, drug, or substance abuse records and mental health records to an insurance company thus exceeded the limitations imposed at 4 Pa code 255.5(b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing.
Client #6 was admitted on March 7, 2016 and was still an active client at the time of inspection. On a consent form dated 3/7/2016, the facility allowed for the release of the client's alcohol, drug or substance abuse records and mental health records to an insurance company, thus exceeding the limitations imposed at 4 PA Code 255.5 (b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing.
Client #7 was admitted on March 25, 2016 and was still an active client at the time of inspection. On a consent form dated 3/25/2016, the facility allowed for the release of the client's alcohol, drug or substance abuse records and mental health records to an insurance company and government agency, thus exceeding the limitations imposed at 4 PA Code 255.5 (b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing.
Client #8 was admitted on March 10, 2016 and was still an active client at the time of inspection. On a consent form dated 3/10/2016, the facility allowed for the release of the client's alcohol, drug or substance abuse records and mental health records to an insurance company and government agency, thus exceeding the limitations imposed at 4 PA Code 255.5 (b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing.
Client #9 was admitted on March 19, 2016 and was still an active client at the time of inspection. On a consent form dated 3/19/2016, the facility allowed for the release of the client's alcohol, drug or substance abuse records and mental health records to an insurance company and government agency, thus exceeding the limitations imposed at 4 PA Code 255.5 (b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing.
Client #10 was admitted on February 17, 2016 and discharged on March 21, 2016. On a consent form dated 2/17/2016, the facility allowed for the release of the client's alcohol, drug or substance abuse records and mental health records to an insurance company and government agency, thus exceeding the limitations imposed at 4 PA Code 255.5 (b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing.
Client #11 was admitted on February 29, 2016 and discharged on March 16, 2016. On a consent form dated 2/29/2016, the facility allowed for the release of the client's alcohol, drug or substance abuse records and mental health records to an insurance company and government agency, thus exceeding the limitations imposed at 4 PA Code 255.5 (b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28(c) Confidentiality
The facility's consent to release was observed to be out of compliance with 42 CFR and State Law 4 Code 255.5 (b).
POC
System facilities will review and revise consent to release forms to be in compliance with 42 CFR and State Law 4 PA Code 255.5(b). Section to be removed related to the release of Alcohol, Drug, Substance Abuse Records, HIV Testing and Results and Mental Health Records.
Responsibility for insuring initial compliance with be Quality Manager for system facilities. Facility staff will be re-trained to the use of the new forms once revised and approved. At that point Clinical Supervisor will insure ongoing compliance through random weekly auditing of open charts for the first 30 days.
Compliance date June 1, 2016.
Consent to Release forms do not include verbiage that allows for the verbal revocation of the consent.
The Consents to Release forms have been revised to include the verbiage "This consent may be verbally revoked as well as in writing." Staff have been re-trained and have corrected all current charts as of 4/11/16 having patients resign new Consent forms. Nursing Supervisor will insure ongoing compliance through medical record checks on monthly basis moving forward.
Compliance date April 11, 2016.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment in one of one discharge record.
The findings include:
One client record requiring documentation of a decision to involuntary terminate a client's treatment at the project was reviewed on April 4, 2016. Notification of termination was required in one discharge record reviewed.
Client #12 was admitted on November 30, 2015 and administratively discharged on December 11, 2015. The facility failed to inform the client in writing the decision to involuntarily terminate treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.33 Notification of Termination
The facility failed to notify the client, in writing, of a decision to involuntarily terminate a client's treatment.
POC
Commencing April 14, 2016, all Counselors will be retrained regarding procedures associated with Administrative Discharges. These procedures shall include
1) Meeting with the client and reviewing specific reasons for the involuntary discharge, documenting this on the facility "Notification of Treatment Termination: Administrative Discharge" form. A copy of this form will be given to the client.
2) The counselor will review the Appeal process with the client, and provide this information to the client in writing.
3) The counselor will provide the client with written information regarding other facilities to provide continuing care
4) Counselor will document the session in writing as a Discharge Note
5) Counselor will include information regarding client's Administrative Discharge in the Discharge Summary
6) Counselor will place copies of all forms (Notification of Termination/Appeal process, Available facilities, Discharge Note) in client's record.
Person responsible for implementation and ongoing monitoring is the Clinical Supervisor who will audit 100% of patient charts pending administrative discharge on a monthly basis for a period of 3 months to insure ongoing compliance. POC will be implemented by 4/14/16.
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