Observations
Based on a review of the patient records,the facility failed to document consents to release information which include the specific information to be disclosed, and/or the purpose of the disclosure and released information that exceeded what was permissible by 4Pa. Code 255.5(b) (1-6)
The findings include:
Twenty patient records requiring consent to release information were reviewed on August 17-19, 2015. One of twenty patient records reviewed contained released information that exceeded that which is permissible to be released by 4Pa. Code 255.5(b) (1-6), specifically record #7. Additionally, the consents to release information forms did not document all required information in two out of twenty patient records, specifically records #7 and 10.
Patient #7 was admitted to treatment on November 3, 2014 and still active at the time of inspection. Patient record #7 contained a letter from the facility dated 2/28/15 stating the client was in a drug and alcohol treatment program. However the letter did not identify the recipient of the letter or the purpose for the release of information. Additionally, since there was no identified recipient or listed purpose included on the letter it was not possible to determine that a valid consent to release information had been completed.
A consent form had been signed by patient #7 on November 10, 2014 to release information to Lancaster County Prison but it did not specify what information was to be disclosed.
Patient #10 was admitted to treatment on July 27, 2015. A consent form had been signed by the patient on August 3, 2015 to release information to Lancaster County Prison but it did not specify what information was to be disclosed, nor the purpose for the disclosure.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The clinical supervisor will provide a training to all staff on confidentiality on September 29th reviewing 255.5. The consents to release information that were incomplete in what information was being disclosed, we corrected by the counselor. The counselor met with the patients in records 7 and 10 and completed the additional information with the patient?s agreement. The patient then initialed and dated to demonstrate approval of changes on the initial consent. After the training, the clinical supervisor/designee will audit 10% of all active charts for 3 months until 100% compliance is achieved. Continued compliance will be monitored through regular random chart audits by Clinical Supervisor, Lead Counselor and Peer Reviews. |