Observations
The facility failed to obtain an informed and voluntary consent in eleven of fourteen client records reviewed on January 7-8, 2019.
Client record # 1 documented a release of information for a funding agency. The release included specific information which exceeded the limits of 255.5.
Client record # 3 documented a letter to the client's probation officer. The letter identified the substance abused by the client.
Client record # 4 documented a release of information for a funding agency. The release included specific information which exceeded the limits of 255.5.
Client record # 5 documented a release of information for a funding agency. The release included specific information which exceeded the limits of 255.5. The record also documented a letter to the probation officer that identified the substance abused by the client.
Client record # 7 documented a letter to the probation officer that identified the substance abused by the client.
Client record # 8 documented a release of information for a funding agency. The release included specific information which exceeded the limits of 255.5.
Client record # 9 documented a letter to the client's probation officer. The letter identified the substance abused by the client.
Client record # 10 documented a release of information for a funding agency. The release included specific information which exceeded the limits of 255.5. The record also documented a letter to the probation officer that identified the substance abused by the client.
Client record # 12 documented a letter to the probation officer that identified the substance abused by the client.
Client record # 13 documented a letter to the probation officer that identified the substance abused by the client.
Client record # 14 documented a letter to the probation officer that identified the substance abused by the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Program Supervisor will conduct a mandatory staff meeting scheduled to occur on Monday, February 4, 2019 for the purposes of re-educating all staff on Drug and Alcohol Confidentiality and, moreover, for refraining from divulging drug-specific indicators in letters to external providers. All staff will sign the meeting minutes verifying understanding of the expectation, and staff who are absent will be required to review in individual session with the Program Supervisor.
Program Director is scheduled to meet with Administrative Assistance (staff in charge of activating, de-activating, and modifying Electronic Health Record forms) on Wednesday, January 30, 2019. Release of information forms will be modified in the electronic health records to include only the components of code 255.5 which permits the release of the following information with informed client consent and signature:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
All other release forms will be de-activated by 2/4/2019 and the staff will be instructed to discard any paper versions of said forms. The Program Director and Program Supervisors will announce the changes once they have gone into effect by 2/4/2019.
As follow-up procedure, the Program Supervisor will conduct random chart reviews for one month to ensure releases are completed correctly. In addition, Program Supervisor will check the releases for clients who are being staffed during that one month time span for individual supervision as an extra layer of checking to make sure releases are being completed accurately. The corrective action will be in place on February 4, 2019. |