Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent in records, #4 and 6. Additionally, consent to release information forms in client records #5 and 8 were missing required information.
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.
Client #4 - It was documented in the client chart that the facility released the client 's previous medication and details of past trauma to the funding source on September 28, 2015 which exceeded 4 PA Code 255.5.
Client #5 - It was documented in the client chart that the facility failed to get the clients date of signature on three consent to releases dated August 7, 2015.
Client #6-It was documented in the client chart that the facility released the client 's previous medication, details of client's relapse, and the drug the client was using to the funding source on December 21, 2015 which exceeded 4 PA Code 255.5.
Client #8 - It was documented in the client chart that the facility failed to get the client 's date of signature on two consent to releases dated September 29, 2015.
These findings were reviewed with facilty staff during the licensing process.
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Plan of Correction
Division Director and Clinical Supervisor met with staff on 6/8/2016 to review what information is allowable to be released with client signed consent based on PA state confidentiality law. Specifically, we reviewed the five areas of information to which our release is restricted. We are restricted from disclosing any medications (current or history), detailed trauma information, and specific information related to relapse (such as substance). Also, we reviewed the importance of all signed documents (including releases) to be dated. Moving forward, Clinical Supervisor will monitor clinical files for compliance during bi-weekly chart audits - overseen by Division Director.
In order to correct the deficiencies identified in OPEN charts the following actions will be taken: For chart #4 a revision to the PCPC and release of information will be completed with the client on the date of her next scheduled individual session (6/24/16). For chart #8, new releases of information will be signed dated during his next scheduled individual session (6/24/16). The other two charts referenced are closed. |