Observations
Based on the review of administrative records and an interviews with the Project Director, counseling and supervisory staff, the facility failed to document all disclosures of client identifying information in the client record as required at 4 Pa. Code 255.5(a)(10). The findings included:During the course of interviews with the clinical staff to determine what both the formal and informal procedures were at the facility for disclosing and tracking client identifying information, Division staff were made aware of a disclosure log kept by clinical supervisors to track disclosures of client information to the Single County Authority's (SCA) Intensive Case Managers (ICM's). As this issue was explored with the staff and the Project Director, he acknowledged that these documents, or the information contained in them, were not filed in the client record for each individual as required. The disclosure logs were reviewed. These documents tracked specifics of information shared with the ICM's working for the SCA. The dates of the release of information for each client was not documented, nor was there any documentation on the log forms used to indicate who received the information disclosed. This information is required at 4 Pa. Code 255.5(a)(10) and HIPAA at 45 CFR 164.164(c)(1) relating to the program's responsibility to account for disclosures of protected health information. HIPAA requirements at 45 CFR 164.528(b)(2) state that the program must address in the accounting - the date of the disclosure, the name and address of the person who received the information, a description of the disclosed information and a statement of the purpose of the disclosure. The records listed below were acknowledged by the Project Director to be current clients at the Project. Documentation in the disclosure logs noted that disclosures of client identifying information were made to the SCA's in reference to client records # 6, 7, 8, 9, 10 and 11, but there was no indication of whom the information was disclosed to.
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Plan of Correction
All staff were addressed on 12/2/2010 and reminded about the need to properly document all client related correspondence including correspondence to the SCA. New standardized forms have been created for the release of information to the SCA and other common referral sources. Clinical supervisors have been instructed to conduct random follow ups to assure that this information is being properly documented. The Executive Director will follow up periodically with the supervisors to assure that this is being done. |