Observations
Based on a review of client records, the facility failed to adhere to the limitations imposed under 4 Pa. Code 255.5 in one record reviewed and/or allowed for the release of information without a signed consent to release information form from the client.
The findings include:
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.
Ten client records were reviewed on January 6-9, 2015. The facility released information that exceeded the limitations imposed under 4 Pa. Code 255.5 in one client record, specifically record, #2.
Client #2 - Consent to release form dated November 26, 2014 for a government agency, allowed for the release of the following documents: progress notes, initial evaluation and psych evaluation. Additionally, two letters were sent out, one on November 14, 2014 and the other November 24, 2014 addressed "to whom it may concern" with no consent to release on file.
Additionally, the facility failed to document whether or not the client was offered a copy of the consent to release forms in client record, #7.
Client #7 - The facility failed to demonstrate whether or not the client was offered a copy of the consent to releases dated July 25, 2014 and August 7, 2014 for a government agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will oversee that all staff are re-educated via staff meeting to complete all consents thoroughly to include documentation on each consent whether or not the client accepted/refused a copy. Staff will also be re-educated that they must adhere to the limitations of 255.5 and to limit information released to judges, probation or parole officers, insurance company, health or hospital plan, or governmental officials. Staff will also be instructed that any outgoing letters must clearly indicate a specific intended recipient and have a completed corresponding release.
Office Administration will ensure ongoing compliance by checking all releases for completion and for compliance with confidentiality regulations prior to scanning the documents into the electronic record. The Quality Improvement Department will also monitor for ongoing compliance via random chart audits. |