Observations
Based on a review of client records, the facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 when documenting the specific information to be released on the written, informed and voluntary consent from the client in seven of ten client records.
The findings include:
Ten client records were reviewed on August 20 - 21, 2015. Ten client records were reviewed for written, informed and voluntary consents from the client. 4 Pa. Code 255.5 restricts the information to be released to insurance companies to the following: whether or not the client is in treatment, client's prognosis, the nature of the project, a brief description of the client's progress and a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 when documenting the specific information to be released to an insurance company in client records # 1, 2, 3, 5, 6, 8 and 9.
Client # 1 was admitted into treatment on June 1, 2015. A written consent to release information to an insurance company was signed by client # 1 on June 17, 2015. The specific information to be released was listed as follows: academic records, behavior logs, medical reports, psychiatric records, psychological reports and treatment plan. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 when documenting the specific information to be released to the insurance company.
Client # 2 was admitted into treatment on April 2, 2015. A written consent to release information to an insurance company was signed by client # 2 on April 7, 2015. The specific information to be released was listed as follows: academic records, behavior logs, medical reports, psychiatric records, psychological reports and treatment plan. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 when documenting the specific information to be released to the insurance company.
Client # 3 was admitted into treatment on May 11, 2015. A written consent to release information to an insurance company was signed by client # 3 on May 11, 2015. The specific information to be released was listed as follows: academic records, behavior logs, medical reports, psychiatric records, psychological reports and treatment plan. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 when documenting the specific information to be released to the insurance company.
Client # 5 was admitted into treatment on August 22, 2014 and discharged on February 16, 2015. Written consents to release information to an insurance company were signed by client # 5 on August 6 and November 6, 2014. The specific information to be released was listed as follows: academic records, behavior logs, medical reports, psychiatric records, psychological reports and treatment plan. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 when documenting the specific information to be released to the insurance company.
Client # 6 was admitted into treatment on October 14, 2014 and discharged on March 31, 2015. Written consents to release information to an insurance company were signed by client # 6 on October 14, 2014 and January 14, 2015. The specific information to be released was listed as follows: academic records, behavior logs, medical reports, psychiatric records, psychological reports and treatment plan. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 when documenting the specific information to be released to the insurance company.
Client # 8 was admitted into treatment on September 22, 2014 and discharged on March 31, 2015. A written consent to release information to an insurance company was signed by client # 8 on March 22, 2015. The specific information to be released was listed as follows: academic records, behavior logs, medical reports, psychiatric records, psychological reports and treatment plan. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 when documenting the specific information to be released to the insurance company.
Client # 9 was admitted into treatment on July 10, 2014 and discharged on February 12, 2015. A written consent to release information to an insurance company was signed by client # 9 on November 6, 2014. The treatment plan was listed as the specific information to be released. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 when documenting the specific information to be released to the insurance company.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Drug/Alcohol clinical program staff will be retrained by the Clinical Supervisor, to begin 09/15/15 and to be completed no later than 09/30/15 regarding Confidentiality requirements. Monthly review of client records by the Clinical Supervisors and Quality Assurance team will be utilized to ensure compliance with this requirement. Training will be on Confidentiality as outlined by 709.28 (c), specifically as relates to 4 PA Code 255.5 (b), as follows: 4 Pa. Code 255.5 restricts the information to be released to insurance companies to the following: whether or not the client is in treatment, client's prognosis, the nature of the project, a brief description of the client's progress and a short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. |