INITIAL COMMENTS
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This report is a result of complaint investigation conducted on June 4-5, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the complaint investigation, the allegations made against Mercy House were not substantiated but there were additional findings which will require a plan of correction.
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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 the review of the client record, the facility failed to write a policy that complies with applicable D&A laws and regulations.The findings include:A complaint investigation was conducted on June 4-5, 2012. During the investigation one client record was reviewed. The client record contained a Notice of Privacy Practices statement which did not comply with ACT 63 at 71 P.S. subsection 1690.108(b); 42 CFR Part 2, Subpart A, subsection 2.1(b)(1) or 4 PA Code subsection 255.5 (b). Client record # 1- This client was seen for an assessment on 11/9/2011. At that time he signed a Notice of Privacy Practices Statement of Understanding which failed to inform the client that the facility would have to act in accordance with the client's verbal revocation of written consent to release information. The Notices of Privacy Practices Statement informed the client that, "When the client consents in writing, any such written consent may be revoked in writing". The federal regulations at 42 CFR Part 2, Subpart C, subsection 2.31 (c)(3) informs the facility that a disclosure may not be made in reliance of a consent that is known to have been revoked. Clients are permitted to revoke consents to release information verbally and must be informed of this right. The Notices of Privacy Practices Statement also informed the client that: "If there is a situation where the safety of the public or an individual is concerned, Mercy House may be required to notify the intended victim and/or law enforcement officials.." and that: "Under HIPAA you have the right to request restrictions on certain uses and disclosures of your treatment information. Mercy House may not be required to agree to any restrictions you request...". The facility failed to inform the client of the requirements and procedures for obtaining a court order to warn a third party and of the requirement to inform the client as soon as possible that the disclosure was made. The facility failed to inform the client that, except for a court order, the facility could release only that information agreed to by the client.The findings were reviewed with the Project Director and were not disputed.
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Plan of Correction
Office manager changed and removed all HPPA forms on June 7, 2012 to reflect that the facility would act in accordance with the client's verbal or written revocation of written consent to release information. The statement about notifying an intended victim constituting "a duty to warn" was removed on June 7, 2012 by office manager and the phrase,"except for a court order", the facility could release only that information agreed to by the client,and client would be notified as soon as possible of the disclosure " was added. Facility manager approved revisions. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of the client record, the facility failed to document a purpose for each consent to release information in one record reviewed.The findings include:A complaint investigation was conducted on June 4-5, 2012. During the investigation one client record was reviewed. The client record contained a consent to release information which failed to identify a purpose for the release. Client record # 1- This client was seen for an assessment on 11/9/2011. At the time of his intake he was asked to sign a consent to release information to a government entity. The consent to release information form did not include a purpose for the release of information. The finding was reviewed with the Project Director and was not disputed.
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Plan of Correction
On June 7, 2012
On Form --"Authorization for Release of Information," office manager, amended the form by adding the line: The purpose of release: ______________________________________, to the form.
Old forms were removed and replaced with new ones. Facility director approved revisions |