Observations
Based on a review of 14 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 8 records. Additionally, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 2 records and a consent to release information form was missing the purpose of the disclosure in 1 record.
Client # 3 was admitted on 4/27/17 and was still an active client at the time of the inspection. A consent to release form was signed and dated on 4/6/17 to a probation officer that exceeded 4 Pa. Code 255.5 (b) and allowed for the release of the discharge summary, histories and physicals, diagnosis, face sheet, consultations, lab reports and EKGs, instances of relapse into substance abuse, and other: open release.
Client # 6 was admitted on 4/25/16 and was discharged 5/19/16. A consent to release form was signed and dated on 4/7/16 to the funding source, pharmacy, probation and parole, referral source, employer after care, primary care physician, emergency contact, and family member which exceeded 4 Pa. Code 255.5 (b) and allowed for the release of the discharge summary, aftercare, treatment plans, referral source, histories and physicals, diagnosis, consultations, face sheet lab reports and EKGs, and instances of relapse into substance abuse.
Client # 7 was admitted on 06/20/16 and was discharged on 8/1/16. A consent to release form was signed and dated on 6/4/16 to a government agency which exceeded 4 Pa. Code 255.5 (b) and allowed for the release of the discharge summary, aftercare, treatment plans, referral source, histories and physicals, diagnosis, consultations, face sheet lab reports and EKGs, and instances of relapse into substance abuse.
Client # 8 was admitted on 3/20/1017 and was an active client at the time of the inspection. A consent to release form was signed and dated on 2/3/17 to a government agency which exceeded 4 Pa. Code 255.5 (b) and allowed for the release of the discharge summary, aftercare, treatment plans, histories and physicals, referral source and face sheet.
Client # 11 was admitted on 9/15/16 and was discharged on 11/22/16. A consent to release form was signed and dated on 5/24/16 to the funding source which exceeded 4 Pa. Code 255.5 (b) and allowed for the release of the discharge summary, aftercare, treatment plans, diagnosis, histories and physicals, referral source and face sheet, lab reports and EKGs.
Client #12 was admitted on 8/19/16 and was discharged on 3/3/17. A consent to release form was signed and dated on to the client's employer which exceeded 4 Pa. Code 255.5 (b) and allowed for the release of the discharge summary, aftercare, treatment plans, diagnosis, histories and physicals, referral source and face sheet, lab reports and EKGs. Additionally, that same form did not include the purpose of the disclosure.
Client # 13 was admitted on 8/26/16 and was discharged on 1/3/17. There was documentation that a facsimile was sent to an attorney on 11/15/16; however, there was no consent to release information form signed by the client prior to the disclosure of information.
Client # 14 was admitted on 9/7/16 and was discharged on 2/16/17. There was documentation that a facsimile was sent to a hospital on 9/29/16; however, there was no consent to release information form signed by the client prior to the disclosure of information.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will be trained on the 4 PA Code 255.5. This will be ensured by the Clinical Supervisor under the direction of the Chief Clinical Officer. Compliance to this code will be monitored via weekly chart reviews. |