Observations
Based on the review of administrative materials and interviews with the Project and Facility Directors, the facility failed to document Qualified Service Organization Agreements or consents to release information for entities which provide services to the project and in providing those services are exposed to client identifying information.
The findings include:
Administrative materials including policies and procedures and letters of agreement were reviewed during the annual licensure renewal inspection conducted on September 24-28, 2012. There was no documentation of Qualified Service Organization Agreements (QSOA)or consents to release information for businesses that provide services to the Project. There was no documentation of a QSOA or individual consent to release information forms for releases of information to a pharmacy.
Interviews with the Project and Facility Directors on 9/25/2012 verified that no such agreements or consents to release were documented at the time of the inspection . The findings were reviewed with the Directors and were disputed, but no additional documentation was provided to demonstrate that the requirements of this regulation were met.
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Plan of Correction
DARS, Inc. Supervised Independent Living Program will develop and maintain Qualified Service Organization Agreements (QSOA) with contracted service agencies to ensure that restrictions related to client confidentiality set forth at 42 C.F.R. and at 4 Pa. Code 255.5 are maintained. QSOA's will be developed with all current contracted service providers including, but not limited to, the Queen Street Pharmacy, which was established on October 26, 2012. All other releases of client information will be obtained and maintained by the primary counselor through signed release of information forms filed in the individual client's file. All QSOA's will be developed by the Treatment Director, and maintained with Administrative materials. Any future contracted agencies will be required to sign a QSOA prior to completing a service. This again will be developed and maintained by the Treatment Director. |