Observations
Based on the review of client records, the facility failed to comply with 4 Pa. Code relating to projects and coordinating bodies: disclosure of client-oriented information.
The findings include:
On September 7, 2011 six client records were reviewed for documentation of informed and voluntary consent, specifically records # 1, 2, 3, 4, 5 and 6. The facility documented the release of client information which exceeded the limitations of 4 Pa. Code in client records # 1, 2, 3, 4, 5 and 6.
Client records # 1, 2, 3, 4, 5 and 6 contained a signed general consent to release information form that stated:
"Although the medical records of your treatment with this facility are confidential, there are specific conditions under which information contained in your files may be released. The conditions are as follows:
To the Mental Health Administration pursuant to his duties under applicable statutes and regulations.
To the Court or Mental health Review Officer in the course of legal proceedings.
To an attorney who may be assigned to conduct a defense at a commitment hearing.
To appropriate personnel pursuant to regulations governing drug and alcohol abuse or dependence.
To Parents or guardians and others when necessary to obtain consent to medical treatment."
Client # 1 was admitted on 6/13/11. The general consent to release information form in client record # 1 was signed by the client on 6/23/08.
Client # 2 was admitted on 5/2/11. The general consent to release information form in client record # 2 was signed by the client on 5/2/11.
Client # 3 was admitted on 2/28/11. The general consent to release information form in client record # 3 was signed by the client on 2/28/11.
Client # 4 was admitted on 3/9/11. The general consent to release information form in client record # 4 was signed by the client on 3/9/11.
Client # 5 was admitted on 3/21/11. The general consent to release information form in client record # 5 was signed by the client on 3/21/11.
Client # 6 was admitted on 8/22/11. The general consent to release information form in client record # 6 was signed by the client on 11/19/09.
The findings were confirmed by the Director on September 8, 2011.
This is repeat citation. The facility was cited on February 3, 2011 for failing to comply with 4 Pa. Code
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |