Observations
Based on a review of client records, the facility failed to obtain a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in one of five client records. In addition, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when documenting the specific information to be released to an employer in one of five client records.
The findings include:
Five client records were reviewed on July 28, 2015. Five client records were required to include documentation of written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client prior to disclosing information contained in the client record to an outside laboratory in client record # 4. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 when documenting the specific information to be released to an employer in client record # 5.
Client # 4 was admitted into treatment on May 15, 2014. A urine sample was released to an outside laboratory for drug testing on May 28, 2015. The facility failed to obtain a written, informed and voluntary consent from client # 4 prior to disclosing information contained in the client record to an outside laboratory. A written consent to release information to this laboratory was not documented until June 11, 2015.
Client # 5 was admitted into treatment on July 2, 2015. A consent to release information to the employer was signed by client # 5 on July 2, 2015. This written consent indicated the specific information to be released to the employer would include the following: whether or not the client has relapsed and frequency, a description of the client's prognosis/diagnosis, nature of the project and a brief description of the client's progress. This exceeded the limitations imposed at 4 Pa. Code 255.5 which states information released to an employer shall be limited to whether the client has or is receiving treatment with the project.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director retrained staff during a Departmental Meeting held on 6.2.2015 and 6.17.2015 on confidentiality and the process of obtaining the necessary documentation needed before a disclosure can occur. Staff was again retrained on confidentiality pertaining to what information can released during Departmental Meetings held on 8.4.2015 and 8.5.2015. Chart reviews will continue on a monthly basis to prevent missed paperwork and other needed documentation.
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