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 ten of twelve 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.
Twelve client records requiring proper releases of information were reviewed on May 22, 2015. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client record, #2, 3, 4, 5, 6, 7, 8, 9, 11, and 12.
Client #2 was admitted to treatment on June 27, 2014 and was still an active client at time of the inspection. A release of information to the probation officer was signed on 6/17/2014 and a release of information to a court was signed on 6/17/2014 and both release forms allowed for the disclosure of the client's treatment plan goals and discharge/aftercare planning, which exceeded 255.5.
Client #3 was admitted to treatment on November 25, 2014 and was still an active client at time of the inspection. Two separate release of information forms to the probation officer, one signed on 10/28/2014 and one signed on 11/25/2014, allowed for the disclosure of the client's treatment plan goals and discharge/aftercare planning, which exceeded 255.5.
Client #4 was admitted to treatment on February 23, 2015 and was still an active client at time of the inspection. A release of information form to the probation officer signed on 2/23/2015, allowed for the disclosure of the client's treatment plan goals and discharge/aftercare planning, which exceeded 255.5.
Client #5 was admitted to treatment on July 22, 2014 and was still an active client at time of the inspection. A release of information to the probation officer was signed on 722/2014 and a release of information to a court was signed on 7/22/2014 and both release forms allowed for the disclosure of the client's treatment plan goals and discharge/aftercare planning, which exceeded 255.5.
Client #6 was admitted to treatment on December 23, 2014 and was discharged on April 7, 2015. A release of information form to the probation officer signed on 12/23/2014, allowed for the disclosure of the client's treatment plan goals and discharge/aftercare planning, which exceeded 255.5.
Client #7 was admitted to treatment on March 27, 2014 and was discharged on December 18, 2014. Two separate release of information forms to the probation officer, one signed on 2/28/2014 and one signed on 3/27/2014, allowed for the disclosure of the client's treatment plan goals and discharge/aftercare planning, which exceeded 255.5.
Client #8 was admitted to treatment on May 30, 2014 and was discharged on October 31, 2014. Two separate release of information forms to the probation officer, one signed on 5/06/2014 and one signed on 5/30/2014, as well as a release of information to a government agency signed on 5/30/2014, and all three releases allowed for the disclosure of the client's treatment plan goals and discharge/aftercare planning, which exceeded 255.5.
Client #9 was admitted to treatment on February 10, 2014 and was discharged on November 28, 2014. Two separate release of information forms to the probation officer, one signed on 2/04/2014 and one signed on 2/10/2014, allowed for the disclosure of the client's treatment plan goals and discharge/aftercare planning, which exceeded 255.5.
Client #11 was admitted to treatment on August 4, 2014 and was discharged on February 20, 2015. A release of information form to the probation officer signed on 8/04/2014, allowed for the disclosure of the client's treatment plan goals and discharge/aftercare planning, which exceeded 255.5.
Client #12 was admitted to treatment on May 27, 2014 and was discharged on November 3, 2014. A release of information form to the probation officer signed on 5/27/2014, allowed for the disclosure of the client's treatment plan goals and discharge/aftercare planning, which exceeded 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Monday June 1, 2015 new intake packages (including revised releases of information - with wording not to exceed limits established by 4 Pa. code 255.5 b) will be distributed to all clinicians and case managers. In addition, clinicians will be asked to update existing release forms in all active charts to reflect the revised releases. Clinical Supervisor will oversee this and Program Director will monitor for compliance. |
Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information, to include the name of the person, agency, or organization to whom the disclosure is made to, was obtained in three of twelve client records reviewed.
The findings included:
Twelve client records requiring complete informed and voluntary consent to release information forms were reviewed on May 22, 2015. The facility failed to ensure that a completed, informed and voluntary consent to release information form was obtained in client records, #3, 4, and 12.
Client #3 was admitted to treatment on November 25, 2014 and was still an active client at the time of the inspection. A release of information was signed and dated on 10/28/2014 with the purpose of "assess and evaluate external support system & to maintain linkage between treatment and family/friends"; however; the release of information did not include the name of the person, agency, or organization to whom the disclosure was made to.
Client #4 was admitted to treatment on February 23, 2015 and was still an active client at the time of the inspection. A release of information was signed and dated on 2/23/2015 with the purpose of "assess and evaluate external support system & to maintain linkage between treatment and family/friends"; however; the release of information did not include the name of the person, agency, or organization to whom the disclosure was made to.
Client #12 was admitted to treatment on May 27, 2014 and was discharged on November 3, 2014. A release of information was signed and dated on 5/27/2014 with the purpose of "assess and evaluate external support system & to maintain linkage between treatment and family/friends"; however; the release of information did not include the name of the person, agency, or organization to whom the disclosure was made to.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Monday June 1, 2015 all active charts will be reviewed to ensure that no blank consent to release forms are included. Additionally, new intake packages (including revised releases of information - with wording not to exceed limits established by 4 Pa. code 255.5 b) will be distributed to all clinicians and case managers. In addition, clinicians will be asked to update existing release forms in all active charts to reflect the revised releases. Clinical Supervisor will oversee this and Program Director will monitor for compliance. |