Pennsylvania Department of Health
CROZER-CHESTER MEDICAL CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CROZER-CHESTER MEDICAL CENTER
Inspection Results For:

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CROZER-CHESTER MEDICAL CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
This report is the result of a Department of Human Services, Chapter 5100 Mental Health Procedures Act Survey conducted on May 30, 2024, at Crozer-Chester Medical Center. It was determined the facility was not in compliance with requirements of the Chapter 5100 Mental Health regulations.

Plan of Correction:

5100.34 (f)(1-8) REQUIREMENT Consensual Release to Third Parties:

5100. 34 CONSENSUAL RELEASE TO THIRD PARTIES

(f) Each facility shall prepare a form for the use in the voluntary release of records which shall meet the following requirements:
(1) A time limit (date span)
(2) Identification of record recipient
(3) Purpose of record release
(4) A statement identifying the specific relevant and timely information to be released.
(5) A place for signature of the client/patient or parent/guardian and the date, following a statement that the person understands the nature of his release.
(6) A signature place for the staff person who obtained the person's consent.
(7) A place to record verbal consent when the person is physically unable to provide a signature and a place for the signature of two witnesses.
(8) Indication that the consent is revocable.

Observations:

Based upon review of facility policy, documents, medical records (MR), and interviews with staff (EMP), it was determined the inpatient behavioral health unit failed to follow the facility policy "Release of Information" for four of ten medical records reviewed (MR3, MR4, MR5, and MR6).

Findings include:

Review of the Policy "Release of Patient Information" with an effective date of 07/07/2020, last reviewed 04/29/2024 revealed "It is the policy of CKHS hospitals to safeguard the privacy and confidentiality of patient health information. Due to the highly sensitive nature of information related to mental health, information released to individuals and/or organizations outside the Crozer- Keystone Health System is provided only when a valid authorization is completed by the patient or his legal guardian. ... Consensual Release: For consensual release of information to third parties, an authorization to release medical records will be completed. The authorization to release medical records form will include the following:
1. Patient demographic information
2. Identification of the agency or person to whom the records are to be released
3. A limit on its validity which show starting and ending dates
4. Specific purposes for which the released records are to be sent
5. A statement identifying the specific relevant and timely information to be released
6. A place for the signature of the patient or guardian and the date following a statement the person understands the nature of his release
7. A place for the signature of a staff person obtaining the consent of the patient or guardian and the date
8. A place to record a verbal consent for release of information given by a person physically unable to provide a signature and a place
for the signatures of two responsible persons who witnessed the person understood the nature of the release and freely gave his
verbal consent
9. An indication that the consent is revocable at the written request of the person giving consent, or oral request information regarding current ..."

Review of the document "AUTHORIZATION TO RELEASE MEDICAL RECORDS" form revealed the following areas are to be completed: "Patient Name: Today's Date: ... I request a copy of my health records to be sent to: ... Health Records to copied and Date(s) of service ... Special Authorization, ... Purpose of Release: the reason I am asking my records to be copied and sent is: ... Unless I withdraw this authorization sooner, this authorization will expire ... Signature of Patient (or patient's authorized agent) ... Witnessed by: .... Verbal Authorization: (Only when patient is unable to sign) ..."

Review of MR3 failed to reveal documentation that all elements described on the Authorization to release medical records form were completed.

Review of MR4 failed to reveal documentation that all elements described on the Authorization to release medical records form were completed.

Review of MR5 revealed Authorization to release medical records form was not present in the medical record.

Review of MR6 revealed Authorization to release medical records form was not present in the medical record.

Interview with EMP1 and EMP2 on May 30, 2024, at approximately 3:30 PM confirmed the release of information forms were blank for MR3 and MR4 and not present for MR5 and MR6 and all information above is accurate.

Plan of Correction - To be completed: 08/02/2024

The Clinical Director of Geropsych and the Interim Clinical Director of CNAP will ensure that 100% of available Behavioral Health Nurses, Social Workers and Patient Care Secretaries will be educated on the policy titled "Release of Patient Information." Education will be completed by 8/2/24.

The Clinical Director of Geropsych and the Interim Clinical Director of CNAP or a designee will complete 5 audits per week on charts to ensure that release of information forms are being completed for every patient in compliance with hospital policy. Any identified instance of noncompliance will be immediately addressed with the staff identified and reported to the Associate Chief Nursing Officer. Audits will continue until three consecutive months of 100% compliance has been achieved.

All audit data will be reported monthly to the Quality of Care Committee by hospital leadership.

The Associate Chief Nursing Officer is ultimately responsible for this plan of correction.

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