Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information in four out of ten client records.
The findings include:
Ten client records were reviewed on February 12, 2010. All ten records required documentation of informed and voluntary consent. The facility did not document informed and voluntary consent for the release of information in client records 1, 2, 7, and 9.
Client record #1 did not contain documentation of the client's right to verbally revoke a signed consent for the release of information. The facility documented that the client must revoke the consent in writing.
Client record #2 contained documentation of the release of "urine drug screen results" to Treatment Court.
Client record #7 did not contain documentation of the client's right to verbally revoke a signed consent for the release of information. The record contained several consents to government agencies where the facility documented that the client must revoke the consent in writing.
Client record #9 did not contain documentation of the client's right to verbally revoke a signed consent for the release of information to a PC. The facility documented that the client must revoke the consent in writing.
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Plan of Correction
On March 2, 2010 The Division Director located and removed all consent forms that omitted the clients right to verbally revoke his/her consent to release information. All consent forms currently in use by staff indicate that a client may revoke his/her consent to release information verbally or in writing. The Division Director will monitor all consent forms weekly and in individual staff supervision to ensure ongoing compliance.
The Division Director will also conduct a training for staff regarding the release of client information to entities covered under 4 PA code 255.5. This training will be conducted on Apirl 6, 2010. The Division Director will be responsible for monitoring client records weekly to ensure compliance. |