Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in seven of seven records reviewed. Additionally, the one client record contained a consent to release information form that was missing a required element.
Client #1 was admitted on 4/20/16 and was discharged on 8/5/16. The record contained a referral to a transportation company, dated 5/3/16, which identified the client ' s presence in treatment and the nature of the project. However, the record did not contain a consent to release information form for the agency at the time of the inspection.
Client #2 was admitted on 3/9/16 and was discharged on 12/29/16. The record contained referrals to a transportation company, dated 6/10/16 and 8/19/16, which identified the client ' s presence in treatment and the nature of the project. However, the record did not contain a consent to release information form for the agency at the time of the inspection. Additionally, the record did not contain a consent to release information form for the funding source at the time of the inspection and there was evidence of disclosure of information.
Client #3 was admitted on 12/20/16 and was discharged on 4/3/17. The record contained a referral to a transportation company, dated 1/5/17, which identified the client ' s presence in treatment and the nature of the project. However, the record did not contain a consent to release information form for the agency at the time of the inspection.
Client #4 was admitted on 1/25/17 and was discharged on 5/5/17. The record contained a referral to a transportation company, dated 3/7/17, which identified the client ' s presence in treatment and the nature of the project. However, the record did not contain a consent to release information form for the agency at the time of the inspection. Also, the record contained a consent to release information form to a probation officer that was not signed or dated by the client.
Client #5 was admitted on 6/27/17 and was an active client at the time of inspection. The record contained a referral to a transportation company, dated 7/6/17, which identified the client ' s presence in treatment and the nature of the project. However, the record did not contain a consent to release information form for the agency at the time of the inspection.
Client #6 was admitted on 4/20/17 and was an active client at the time of inspection. The record contained a referral to a transportation company, dated 5/17/17, which identified the client ' s presence in treatment and the nature of the project. However, the record did not contain a consent to release information form for the agency at the time of the inspection.
Client #7 was admitted on 5/25/17 and was an active client at the time of inspection. The record contained a referral to a transportation company, dated 6/7/17, which identified the client ' s presence in treatment and the nature of the project. However, the record did not contain a consent to release information form for the agency at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Explanation:
The form for Consent to Release (Informed & Voluntary information) did not contain release of information requirements for transportation services. PPMC misunderstood its responsibility to obtain the release for transportation services, as the transportation services are provided and reimbursed by Philadelphia's Community Behavioral Health (CBH). The outpatient program did not have an audit process implemented for its Consent to Release-Informed & Voluntary form to assure that all of its consent forms were properly signed.
Actions and Proposed Timeframe for Achieving Compliance:
Consent to Release ?Informed and Voluntary form was revised to include a means to document the release of information related to transportation service. This form is completed once per episode of care at the time of intake. Completion date: 8/25/17.
The clinical supervisor or designee will educate staff and clinicians (Staff) responsible for completion of the Consent to Release (Informed and Voluntary) standard requirement on the following:
- The Staff will be re-educated on the elements of the Consent to Release- Informed and Voluntary form, and how to accurately complete of the form.
- The Staff will be re-educated on the requirement to obtain the specific release of information for transportation services for impacted patients.
- The Staff will be re-educated on the requirement to obtain release of information for every agency receiving patient information
- Staff attendance and completion of these education requirements will be documented.
- All currently open case records will be reviewed and identified for completion of the consent to release information to the by the counselors. The new consent to release information to the transportation service will be completed by the counselors with the clients. The Supervisor will confirm that all appropriate records will have the completed consent for the release of information to the transportation company.
Completion Date: 9/30/17
Methodology for Achieving and Maintaining Compliance:
A Quality Assurance audit process will be designed to include a review of the Consent to Release- Informed Voluntary form for thirty clients per month, which shall include all new patients receiving transportation services. The audit will continue until four consecutive months of compliance has been achieved.
The data will be reported to the Behavioral Health/Drug and Alcohol Unit Based Clinical Leadership (UBCL) Committee. The Committee will evaluate the results and implement any further process changes including but not limited to audits frequency.
The audit will begin following completion of Staff re-education.
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