Observations
Based on a April 29 through May 1, 2008 review of client records, the facility failed to obtain an informed and voluntary consent to release information form in three of three records reviewed, # 1, 2 and 3. The specific information to be disclosed exceeded that allowed by the limitations imposed at 4 Pa. Code, Chapter 255.5.
Client record # 1 contained a consent to release form to parole that allowed for the release of the admission summary, psychiatric evaluation, discharge summary and medications. A consent to release form to an insurance company allowed for the release of the client's psychiatric evaluation and medications. A consent to release information form to the county assistance office allowed for the release of the client's psychiatric evaluation and medications.
Client record # 2 contained a consent to release information forms to a parole officer and the county assistance office that allowed for the release of the client's admission summary, psychiatric evaluation and medications.
Client record # 3 contained a consent to release information from to an insurance company that allowed for the release of the client's admission summary, psychiatric evaluation and medications. A consent to release form for the probation office allowed for the release of the clients's admission summary, psychiatric evaluation, discharge summary and medications.
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Plan of Correction
The Clinicval Supervisor will meet with the staff outlining the information that is allowed to be released per 4 Pa. Code, Chapter 255.5; Prognosis, Nature of project, Client Treatment Status, Client Progress, and Statement of Relapse. This will be completed within twoo weeks.
Client ROI's will be reviewed by the Clinical Supervisor periodically for accuracy over the next two months. |