Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in four of seven client records.
The findings include:
Seven client records requiring informed and voluntary consent to release information forms were reviewed on 1/13/16. The facility failed to demonstrate efforts towards allowing clients to revoke authorization of consent, in accordance with 45 CFR 164.508 (b)(5) and 42 CFR 2.31 (a)(8), in client records #3, 4, 5, and 7. Additionally, the facility exceeded the limitations imposed in 4 Pa. Code, Subsection 255.5(b) as it pertains to the information authorized to be released per the the informed and voluntary to release information forms in client record #3.
Client # 3 was admitted into treatment on 12/21/15 and was still active at the time of the inspection. The client's record contained a consent to release information form to a law enforcement agency, which was signed and dated on 12/21/15. This consent form specified that the consent would remain in effect and could not be revoked by the client until the consent form's specified expiration date of 12/31/16. Additionally, the client's record contained a consent to release information form to an insurance company, which was signed and dated on 12/21/15. This consent form authorized the release of the client's discharge summary and counselor progress notes.
Client # 4 was admitted into treatment on 12/28/15 and was still active at the time of the inspection. The client's record contained a consent to release information form to a law enforcement agency, which was signed and dated on 12/28/15. This consent form specified that the consent would remain in effect and could not be revoked by the client until the consent form's specified expiration date of 1/28/16.
Client # 5 was admitted into treatment on 11/13/15 and was discharged on 12/11/15. The client's record contained a consent to release information form to a law enforcement agency, which was signed and dated on 11/13/15. This consent form specified that the consent would remain in effect and could not be revoked by the client until the consent form's specified expiration date of 11/13/16.
Client # 7 was admitted into treatment on 11/30/15 and was discharged on 1/8/16. The client's record contained a consent to release information form to a law enforcement agency, which was signed and dated on 11/30/15. This consent form specified that the consent would remain in effect and could not be revoked by the client until the consent form's specified expiration date of 11/30/16.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On January 14, 2016 the consent used for law enforcement was updated, allowing clients to revoke authorization of consent, in accordance with 45 CFR 164.508 (b)(5) and 42 CFR 2.31 (a)(8). Staff was trained on the use of the new release, and the new release has replaced the previous version in all clinical charts. Staff was also trained on the use of the insurance release, to assure that clients did not select to release any information which did not fall in accordance with 45 CFR 164.508 (b)(5) and 42 CFR 2.31 (a)(8). Beginning February 1, 2016, all clinical charts will be reviewed by the Program Coordinator on a monthly basis to assure all an informed and voluntary consent forms have been completed correctly. As of February 1, 2016 the agency will be in full compliance with licensing regulation 709.28. |