Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client that included the specific information to be disclosed in three of seven client records reviewed on December 8, 2020.
The facility obtained a consent to release information from the client during the intake process that did not include the specific information to be disclosed to the emergency contact in the following client records:
Client # 1 was admitted February 26, 2020 and discharged June 22, 2020.
Client # 3 was admitted April 14, 2020 and discharged July 28, 2020.
Client # 4 was admitted May 19, 2020 and discharged August 11, 2020.
In addition, drug screen results for client # 3 were faxed to the probation officer on the following dates: June 4, June 15 and July 24, 2020. A consent to release information was obtained. However, the specific information disclosed exceeded the limitations imposed by 4 Pa. Code 255.5.
The findings were reviewed with facility staff during the licensing process.
The is a repeat citation from the January 21, 2020 licensing inspection.
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Plan of Correction
The violation occurred due to the release of information not including the specific information to be disclosed to the emergency contact. To ensure this deficiency does not reoccur, the Program Director added the nature of the emergency and the location of the client to the document. Moving forward, this is the emergency contact release of information that will be utilized. As per protocol, the client will initial and give consent by the specific information disclosed. The Program Director instructed the staff that this is the only emergency contact release of information that is to be utilized. The Program Director and Compliance Officer will conduct random chart reviews each month to ensure staff are implementing and utilizing this new release. At treatment team meetings, the Program Director will review the plan of correction with staff to ensure their understanding.
The violation occurred because the therapist faxed a drug screen to the probation officer. To ensure this deficiency does not reoccur, on 12/15/2020, the Program Director and Compliance Officer gave each therapist a copy of Code 255.5 to gain an understanding of the limitations when releasing information. Code 255.5 was reviewed and each therapist was instructed to sign and date the document acknowledging their understanding. At weekly treatment team meetings, a discussion will occur with all staff regarding outgoing correspondence. Randomly, the Program Director and Compliance Officer will be responsible for reviewing outgoing correspondence on a monthly basis to ensure the procedure as per 255.5 has been followed.
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