Observations
Based on a review of client records it was determined that the facility failed to include the specific information that would be released on the consent to release information form. Client records # 2 and 3 contained consent to release information forms to family members, significant others and/or friends in the event an emergency contact was required. The consent forms did not specifically state what information would be released in the event of an emergency. Client record # 3 documented a Pennsylvania Client Placement Criteria continuing stay document which was submitted to a funding entity where the information included exceeded the limitations on the release of information established at 4 Pa. Code subsection 255.5(b).
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Plan of Correction
The clinical staff person obtained a consent to release information in the event of an emergency, however, the clinical staff person did not specify what information would be released in the event of an emergency. When a consent to release information in the event of an emergency is obtained the clinical staff person will specify what information is to be disclosed (e.g. location, nature of emergency).
The clinical staff person also had a conintuing stay PCPC in a client record where information exceeded the limitations of 4 Pa.Code subsection 255.5(b). The clinical staff person will ensure that any future PCPCs will adhere to the limitations of 4 Pa. Code 255.5(b).
This standard is in compliance effective 9/21/2007. The Facility Director and clinical staff person will ensure ongoing compliance with this standard through ongoing supervision, routine quality checks of files and ongoing training.
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