Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent to release in five of twelve client records reviewed during the course of the annual licensing inspection on July 29, 2016.
The findings include:
The facility's consent to release form was observed to be out of compliance with 42 CFR and State Law 4 Pa Code 255.5(b) in client records #5 and #6.
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.
42 CFR, Part 2 states:
The facility also failed to include the following required disclaimer (42 CFR Section 2.32) on their consent form: This information has been disclosed to you from records protected by Federal Confidentiality rules (42 CFR, Part 2). The Federal rules prohibit you from making any further disclosure of the information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR, Part 2. A general authorization for the release of medical or other information is not sufficient for the purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or other drug abuse patients.
In addition, the facility ' s consent to release form did not contain documentation of the client's right to verbally revoke a signed consent for the release of information. The facility's consent to release form documented, "This authorization form may be withdrawn at any time by notifying RHD in writing at the Program address above."
Client #5 was admitted into treatment on April 8, 2016 and was still an active client at the time of inspection. On a consent form dated 4/8/16, the facility allowed for the release of the client's entire medical chart, drug and alcohol records, physical health records, mental health records, face sheet, progress in treatment, diagnosis, consultations, all information pertaining to drug court participation and evaluation, after care service plan and medication records to probation thus exceeded the limitations imposed at 4 Pa code 255.5(b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing and did not include the required 42 CFR Federal disclaimer.
Client #6 was admitted into treatment on February 29, 2016 and was still an active client at the time of inspection. On a consent form dated 5/26/16, the facility allowed for the release of the client's entire medical chart, drug and alcohol records, physical health records, mental health records, face sheet, consultations, diagnosis, information related to DUI evaluation recommendation, after care service plan and medication records to probation thus exceeded the limitations imposed at 4 Pa code 255.5(b). In addition, the facility failed to comply with 42 CFR as the consent required the client to revoke their consent in writing and did not include the required 42 CFR Federal disclaimer.
In addition, the facility failed to obtain a dated signature on a consent to release form in client records #3, #4, and #8.
Client #3 was admitted into treatment on November 16, 2015 and was still an active client at the time of inspection. Two consent to release forms to the client's family member and to a government agency dated 11/16/2015, the facility failed to obtain the date of the client's signature.
Client #4 was admitted into treatment on December 1, 2015 and was still an active client at the time of inspection. Two consent to release forms to the clients family member and to the Drug court team dated 12/1/2015, the facility failed to obtain the date of the client's signature.
Client #8 was admitted into treatment on October 6, 2015 and discharged on February 6, 2016. On a consent to release form to the client's family member dated 10/6/2015, the facility failed to obtain the date of the client's signature.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Consent to release documentation has been revised to reflect the following 5 releases only:
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.
Additionally, the form has been revised to include the signature and date lines of both the client and the presenting staff member.
The form has also been revised to read "I understand that I have the right to revoke this authorization at any time. I understand that my revocation must be either verbal or in writing and addressed to counsel for Resources for Human Development, Inc. c/o 4700 Wissahickon Avenue, Suite 129, Philadelphia PA 19144, attn.: Legal Department. I understand that the revocation does not apply to information that has already been released in response to this authorization. Unless otherwise revoked, this authorization will expire on the following date:."
Consent to Release Information documentation is informed and voluntarily will be completed prior to disclosure of any client information. The Assistant Director will review and provide instruction on the Consent to Release Information policy and procedure with all program staff on 9/16/2016 at the staff meeting. A sign in sheet will be used as proof that the staff have been informed. Post training the form will be added to the Shared Drive and hard copies will be placed in the folder labeled Consent to Release information and placed in the hanging bend in the counselors office.
All staff will check for consent to release before sharing any information about a client, if a consent does not exist, the client will be informed and voluntarily choice whether or not to complete the consent. If consent is not documented the information will not be provided.
All current active charts will be reviewed by Assist Director and Director by 9/30/16 to ensure that all consents are completed. If it is discovered that there is a need the above procedures (informing the client)will be followed to ensure that the proper consents are present.
As it pertains to Client # 3,4,5,6,and 8 the Administrative Assistance will meet with each named client to correct, and update consent in their chart by September 30, 2016. The Assistant Director will review those charts on September 30, 2016 to ensure the task has been completed.
The Program Director and Assistant Director will monitor use of Consent to Release Information through internal chart audits Monthly. |
Observations
Client #9 was admitted to the facility on September 2, 2015 and was administratively discharged on January 9, 2016. The facility failed to inform the client in writing the decision to involuntarily terminate treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff will be trained by the Assistant Director on or by September 16, 2016 on the proper Discharge protocol which will include the Discharge Checklist as well as The Notice of Discharge. Staff attending the training wil indicate that they have been trained by signing off on the sign in shee. Both documents have been added to the Rise Above shared drive under Discharge as of July 26, 2016 to ensure that the necessary documentation is accessible.
As it related to clients being involuntarily discharged, the assigned counselor will meet with the client prior to the discharge to inform them of Rise Above's intent to discharge them involuntarily and the reason for the discharge. At that time the client will be given a written notice of termination of treatment. Both the termination letter and discharge note will be placed in the client's chart.
The Program Director and/or Assistant Director will ensure that this corrective action plan will be completed, implemented, followed on-going through chart audits, and staff meetings. |