Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in three of five client records.
The findings include:
Five client records were reviewed on November 25, 2014. Consent to release information forms were required in all five client records. Consent was not obtained prior to disclosure in records #2, 3 and 4.
Client # 2 was admitted to treatment on July 24, 2014. A consent to release information form for the funding source was not signed by the client as of the date of the inspection.
Client # 3 was admitted to treatment on March 13, 2014, and was discharged on September 22, 2014. A consent to release information form for the funding source was not signed by the client.
Client # 4 was admitted to treatment on April 21, 2014, and was discharged on November 4, 2014. A consent to release information form for the funding source was not signed by the client.
This is a repeat citation from the November 14, 2013 inspection.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 11/25/2014 the Project Director met with the AOD staff in the regularly scheduled weekly team meeting after the exit interview with the licensing field agent. The AOD staff was informed of the failure to obtain proper consent forms from clients for their respective funding sources. The staff was directed to utilize the 5-point consent to release information form (applicable to PA Code 255.5) when asking clients to sign an informed and voluntary consent for the release of information to their funding source, inclusive of all managed care organizations and the single county authority. All AOD staff members were in attendance, verbally indicated their understanding of the deficiency and method of resolving the issue and henceforth committed to be fully compliant with the issue. Also discussed was the review of the client record after the initial intake was completed by the compliance officer to ensure that the proper release of information forms were in place and signed by the client. The AOD staff met on 12/02/14 during a regularly scheduled weekly team meeting and reviewed the CQI form/checklist generated by the Compliance Officer that will be used to verify that specific procedures and documents are complete, accurate and in the medical record. The Compliance Officer will conduct the review of the record within 5 days of the intake, within 5 days of each treatment plan update and within 5 days of the client discharge to verify the completeness of the medical record, which includes but is not limited to the consent to release information forms for all funding sources related to each client. Any deficiencies in the record will be reported to the Project Director. The IFS AOD Continuous Quality Improvement Quarterly Report generated by the Compliance Officer will report any deficient findings in this regard and appropriate training and subsequent disciplinary actions will be taken by the Project Director within 5 days of the CQI report. |
Observations
Based on a review of the client records, the facility failed to demonstrate the clients are informed of their rights in five of five client records.
The findings include:
Five client records were reviewed on November 25, 2014. All five of the client records did not include documentation the clients were informed of all of their rights.
Client #1 was admitted to treatment on May 13, 2014. The client rights form signed by the client did not include all of the clients rights. The client rights form failed to include civil rights, reasons for removing sections shall be documented and kept on file, the right to appeal a decision limiting access, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from the record, and the right to submit rebuttal data or memoranda to the record.
Client #2 was admitted to treatment on July 24, 2014. The client rights form signed by the client did not include all of the clients rights. The client rights form failed to include civil rights, reasons for removing sections shall be documented and kept on file, the right to appeal a decision limiting access, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from the record, and the right to submit rebuttal data or memoranda to the record.
Client #3 was admitted to treatment on March 13, 2014, and was discharged on September 22, 2014. The client rights form signed by the client did not include all of the clients rights. The client rights form failed to include civil rights, reasons for removing sections shall be documented and kept on file, the right to appeal a decision limiting access, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from the record, and the right to submit rebuttal data or memoranda to the record.
Client #4 was admitted to treatment on April 21, 2014, and was discharged on November 4, 2014. The client rights form signed by the client did not include all of the clients rights. The client rights form failed to include civil rights, reasons for removing sections shall be documented and kept on file, the right to appeal a decision limiting access, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from the record, and the right to submit rebuttal data or memoranda to the record.
Client #5 was admitted to treatment on August 21, 2014, and was discharged on October 7, 2014. The client rights form signed by the client did not include all of the clients rights. The client rights form failed to include civil rights, reasons for removing sections shall be documented and kept on file, the right to appeal a decision limiting access, the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from the record, and the right to submit rebuttal data or memoranda to the record.
This is a repeat citation from the November 14, 2013 inspection.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On 12/2/2014 the AOD staff met for the regularly scheduled weekly team meeting wherein the deficiency was discussed and the IFS Policy and Procedures pertaining to PA Code 28. Chapter 709.30 (1-6) [Client Rights] were reviewed. On 12/8/2014, the Project Director revised the Client Rights form that is reviewed and signed by clients at intake to include a statement taken from the IFS policy manual and indicative of regulation 709.30 that clearly indicates the client's civil rights; reasons for removing sections of the client record prior to a client's review and the documentation of the reason for the removal; the maintaining of a file containing the documentation pertaining to the reasons a section of the record was removed; the client's right and method to appeal a decision to limit access to the client record; the client's right and method to request the correction of inaccurate, irrelevant, outdated or incomplete information from the client record; and the client's right and method of submitting rebuttal data or memoranda to the client record.
As well, on 12/8/2014, the CLIENT RIGHTS notice publically displayed in the lobby of the IFS office was also revised accordingly as it is the same form as the Client Rights signature form but without the line for signature present. The revised notice was placed in the lobby on 12/8/2014. |