Observations
During an onsite inspection on April 3-5, 2019, the facility failed to obtain a release that was within the parameters of 4 Pa. Code in one out of fourteen records.
Client #6 was admitted on February 5, 2018 and was active at the time of the inspection. A signed release dated May 1, 2018 to a County Bail officer exceeded the 5 points outlined in 255.5. The release was for the following: admission, attendance, discharge dates, diagnosis, prognosis, drug/alcohol history, psychiatric history, medical history, physical exam, psychosocial exam, progress reports, counselor recommendations, counselor discharge summary, aftercare plan and billing information.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding confidentiality.
We recently switched to a new electronic health record and the release form in question was incorrectly completed by a newer counselor. At no time was any information released beyond the scope of what is permitted by 4 PA Code 255.5.
Effective 4/24/2019 all staff have been reminded of how to correctly complete consent forms, which consent forms to select for different agencies, and the importance of complying with all applicable confidentiality laws including PA Code 255.5.
Consent forms will be regularly reviewed in weekly clinical supervision as well as through weekly random file audits. Director will follow up monthly with clinical supervisors to assure continued compliance.
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