Observations
Based on a review of patient records, the facility failed to keep patient records confidential in accordance with 4 Pa. Code subsection 255.5 when disclosing client-oriented information in one of four patient records.
The findings included:
Five inpatient hospital detoxification patient records were reviewed on May 1 - 2, 2013. Four patient records were reviewed for written informed and voluntary consents to release information. Per 4 Pa. Code subsection 255.5 (a) (6), projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Such information shall be limited to whether the client has or is receiving treatment with the project. The facility exceeded the limitations imposed at 4 Pa. Code subsection 255.5 (a) (6) when disclosing client-oriented information in patient record # 3.
Patient # 3 was admitted into treatment on April 27, 2013. A consent to release information to the employer of patient # 3 was signed by the patient on April 29, 2013. The specific information to be released to the employer was listed as "FMLA papers" (Family and Medical Leave Act). This release of client-oriented information exceeded the limitations imposed at 4 Pa. Code 255.5 (a) (6) which only allows for the release of whether the client has or is receiving treatment at the project.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Clinical Supervisor will hold a staff training on 5/15/13 during our regular staff meeting. All Clinical Specialist will be in attendance and confidentiality regulations will be reviewed. Staff will be re-educated that FMLA papers are beyond the employer confidentiality scope and can only be returned to an EAP or outside FMLA agency. Clinical Specialists will have a signed attendance sheet to be placed in the education record. Clinical Supervisor or designee will hold chart reviews for 3 mos to ensure compliance. |