Observations
Based on a review of client records, the project failed to document informed and voluntary consent to release forms that complied with Pa Code 255.5.
The findings include:
4 Pa. Code 255.5 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
Ten client records were reviewed on January 8, 2016. The project failed to document informed and voluntary consent to release forms in all client records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
The project has a "Managed Care/Insurance Company Authorization to Release Information Form" that all clients sign and agree to consent to release. The "Managed Care/Insurance Company Authorization to Release Information Form" is a project wide template form. The other box is checked off on this template form with the pretext "level of care evaluation."
The Licensing Specialist inquired from the Facility Director about the meaning of "level of care evaluation," at which time the Facility Director stated the "level of care evaluation" was the Biopsychosocial Evaluation or what the project terms Initial or Intake Evaluation.
The release or documentation of the release of the client's "level of care evaluation" does not comply with the stipulations of 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Director conducted a staff training on Confidentiality on Wed 1/20/2016. Site Director reviewed regulations and policies regarding client confidentiality and 4 PA Code 255.5. Staff gained increased knowledge about the restrictions of releasing information as required by law. Facility Director will perform quarterly chart audits to ensure that the appropriate measures are met and that the documentation of confidentiality is properly completed with all consent forms and release of information forms at Rehab After Work.
The current Managed Care Release of Information form was changed on 1-18-16 to comply with 4 PA Code 255.5 regulation of confidentiality. This form will be utilized moving forward for all clients entering treatment at Rehab After Work. Client charts will be audited on a random basis to ensure that the standard is achieved. |