Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in thirteen of thirteen records reviewed.
The findings included:
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Thirteen client records requiring proper releases of information were reviewed on May 13, 2015 and May 14, 2015. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client record's, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13.
Client #1 was admitted to treatment on January 9, 2015 and was still an active client at time of the inspection. A release of information to a government agency was signed on January 12, 2015 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #2 was admitted to treatment on March 23, 2015 and was still an active client at time of the inspection. A release of information to a government agency was signed on March 23, 2015 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #3 was admitted to treatment on December 19, 2014 and was still an active client at time of the inspection. A release of information to a government agency was signed on December 22, 2014 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #4 was admitted to treatment on February 27, 2015 and was still an active client at time of the inspection. A release of information to a government agency was signed on February 27, 2015 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #5 was admitted to treatment on April 10, 2015 and was still an active client at time of the inspection. A release of information to a government agency was signed on April. 13, 2015 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #6 was admitted to treatment on February 11, 2015 and was still an active client at time of the inspection. A release of information to a government agency was signed on February 12, 2015 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #7 was admitted to treatment on April 28, 2014 and was discharged on October 15, 2015. A release of information to a government agency was signed on April 28, 2014 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #8 was admitted to treatment on January 30, 2015 and was discharged on May 11, 2015. A release of information to a government agency was signed on July 30, 2015 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #9 was admitted to treatment on May 30, 2014 and was discharged on September 18, 2014. A release of information to a government agency was signed on June 2, 2014 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #10 was admitted to treatment on November 12, 2014 and was discharged on April 23, 2015. Two release of information forms to two separate government agencies were signed on November 12, 2014 and both allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #11 was admitted to treatment on April 9, 2014 and was discharged on September 25, 2014. A release of information to a government agency and a release of information were signed on April 10, 2014 and both allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #12 was admitted to treatment on July 28, 2014 and was discharged on March 18, 2015. A release of information to a government agency was signed on July 28, 2014 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
Client #13 was admitted to treatment on September 4, 2014 and was discharged on January 7, 2015. A release of information to a government agency was signed on September 4, 2014 and allowed for the disclosure of the client's forwarding address after treatment, which exceeded 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 Confidentiality (a) A written procedure shall be developed by the Project Director which shall comply with 4 Pa. Code 255.5. 4 Pa. Code 255.5 states: Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4), (7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following: (1) Whether the client is or is not in treatment. (2) Client's prognosis. (3) The nature of the project. (4) A brief description of the client's progress. (5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
All staff will ensure that disclosures to the criminal justice system, insurance companies and health or hospital plan, or government officials shall be limited to the following specifics: 1. Whether the client is or is not in treatment 2. Client's prognosis 3. The nature of the project 4. A brief description of the client's progress 5. A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Specifically, forwarding address will be removed from client consents to release information to the Department of Human Services and new consents that meet confidentiality 4 Pa. Code 255.5 will be completed for all current active clients.
The Program Director will review regulation 709.28 Confidentiality and the Gaudenzia policies pertaining to Confidentiality in an all-staff meeting on June 10, 2015, and will obtain written verification that the policies were reviewed and understood. The Program Director and Clinical Supervisor will ensure compliance through monthly CQI case audits.
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Observations
Based on the review of client records, the facility failed to ensure that a copy of the informed and voluntary consent form for the disclosure of information was offered to the client in four of thirteen client records reviewed.
The findings included:
Thirteen client records requiring documentation that the completed informed and voluntary consent to release information forms were offered to the client were reviewed on May 13, 2015 through May 14, 2015. The facility failed to ensure that the informed and voluntary consent to release information forms were offered to the client in client records, # 2, 3, 4, and 6.
Client #2 was admitted to treatment on March 23, 2015 and was still an active client at the time of the inspection. A consent to release form to another treatment facility was signed on May 6, 2015 and there was no indication or documentation that the client was offered a copy of the consent form as of the date of the inspection.
Client #3 was admitted to treatment on December 19, 2014 and was still an active client at the time of the inspection. There was a consent to release form to another treatment facility signed on March 10, 2015, a release of information form to another treatment facility signed on May 8, 2015, a release of information form to a family friend signed on December 23, 2014, and a release of information to a government agency signed on April 30, 2015 in the client record. All four release of information forms did not have any indication or documentation that the client was offered a copy of the consent form as of the date of the inspection.
Client #4 was admitted to treatment on February 27, 2015 and was still an active client at the time of the inspection. A release of information form to a government agency signed on 03/06/2015 and a release of information form to an attorney signed on 03/25/2015 that did not have any indication or documentation that the client was offered a copy of either consent form as of the date of the inspection.
Client #6 was admitted to treatment on February 11, 2015 and was still an active client at the time of the inspection. A release of information form to another treatment facility signed on 03/06/2015 and a release of information form to a government agency signed on 004/07/2015 that did not have any indication or documentation that the client was offered a copy of either consent form as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 Confidentiality. (d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
All staff will fully and correctly complete the informed and voluntary consent form for the disclosure of information and ensure a copy of any signed consent is offered to the client. Documentation of whether or not the client accepted a copy of the consent will be reflected on the consent form by checking (accepted) or (refused).
The Program Director will review regulation 709.28 Confidentiality and the Gaudenzia policy "Client Copies and Maintenance of Consents" in an all-staff meeting on June 10, 2015 and obtain written verification that the policies were reviewed and understood. The Program Director and Clinical Supervisor will ensure compliance via monthly CQI audits and staff supervision. |