Observations
Based on a review of the agency policy manual it was determined that the agency failed to meet the requirements of this regulation because the policy contained components that were inconsistent with applicable confidentiality laws ( 42 CFR; 4PA Code subsection 255.5). Policy language which was noted to be incorrect stated that information could be released without client consent "..to law enforcement when the program has reasonable grounds to suspect that a client has committed a crime". Additional policy language stated that releases without consent were appropriate "... to government agencies that fund or regulate a program" also "...to private organizations that provide financial assistance or 3rd party payments..". In addition the HIPAA disclosure statement contained similar language about releases of information without client consent.
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Plan of Correction
POC
709.28 (a) (1) Licensure
Confidentiality
Why out of compliance?
1. Language in the Agency Manual originated from an incorrect interpretation of the regulation. Incorrect language.... To law enforcement when the program has reasonable grounds to suspect that a client has committed a crime."... also incorrect language... without consent to government agencies that fund or regulate a program"... to private organizations that provide financial assistance or 3rd party payments."
Time-Frame for full compliance:
2. Full compliance when the Board of Directors approves the new Policy on October 24, 2007
Corrective Action Steps:
3. The Executive Director has removed all incorrect language from the Confidentiality Policy. Staff will be trained on the new language during a staff meeting on September 21, 2007 by the Treatment Director. Minutes of the staff meeting/training will be kept on file for review. The Governing Board of Directors will approve the new policy at the next regular Board meeting on October 24, 2007 as an amendment to our Policy and Procedures Manual.
Why out of compliance?
1. The HIPAA Handbook which contains conflicting language was developed by our HIPAA Attorney to be in compliance with HIPAA laws.
Time-Frame for full compliance:
2. New Handbook with added language completed by September 21, 2007; Staff trained during staff meeting/training on September 21, 2007. Minutes of training will be kept on file for review.
Corrective Action Steps:
3. The Handbook has been changed by the Executive Director and a disclaimer added per discussion with the licensing representative: "all information released by Crawford County Drug & Alcohol Executive Commission, Inc. will be in accordance with State and Federal Drug and Alcohol Confidentiality laws including 42 CFR part 2; 4PA Code subsection 255.5. Under Federal regulations governing Confidentiality of Alcohol & Drug abuse Patient Records client records cannot be disclosed without the client's written consent unless otherwise provided for in the regulations. The information released is restricted to the following areas: a. Whether or not the client is in treatment. b. The nature of the project. c. Description of the client's progress. d. Whether the client has relapsed into abuse and frequency of relapse. e. Client's prognosis. Where release of information governed by HIPAA regulations and drug and alcohol confidentiality regulations conflict, the most restrictive will apply.
The Treatment Director will review the changes/additions to the HIPAA Handbook with all staff during a staff meeting/training. Minutes will be kept on file for review. All old HIPAA Handbooks have been destroyed and news ones provided.
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