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.
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Observations:
Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to document on their "PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS" form the signature of the staff person who obtained the consent for the consensual release of medical records for seven of ten medical records reviewed (MR1, MR2, MR3, MR5, MR6. MR7 and MR8).
Findings include:
A review on March 27, 2025, of facility policy "General Guidelines Regarding Release of Information" with an effective date of July 2024, revealed no statement that a staff member who obtained the consent was required to sign the form.
Review of MR1 on March 26,2025 revealed "PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS" was signed by patient, and did not contain the signature of the staff person who obtained the consent.
Review of MR2 on March 26,2025 revealed "PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS" was signed by patient, and did not contain the signature of the staff person who obtained the consent.
Review of MR3 on March 26,2025 revealed "PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS" was signed by patient, and did not contain the signature of the staff person who obtained the consent.
Review of MR5 on March 26,2025 revealed "PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS" was signed by patient, and did not contain the signature of the staff person who obtained the consent.
Review of MR6 on March 26,2025 revealed "PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS" was signed by patient, and did not contain the signature of the staff person who obtained the consent.
Review of MR7 on March 26,2025 revealed "PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS" was signed by patient, and did not contain the signature of the staff person who obtained the consent.
Review of MR8 on March 26,2025 revealed "PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS" was signed by patient, and did not contain the signature of the staff person who obtained the consent.
An interview conducted March 26, 2025, at 11: 30AM with EMP3 confirmed the "PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS" did not contain the signature of the staff person who obtained the consent.
EMP2 confirmed via email on March 28, 2025, at 9:30AM the "General Guidelines Regarding Release of Information" policy does not contain a requirement for staff signature.
| | Plan of Correction - To be completed: 06/03/2025
1.Behavioral health leadership is responsible for the action plan.
2.MR 543.02 form reviewed by nursing leadership and health information management leadership. Updates to MR 543.02 were submitted for change on 3/31/25.
3.Education on changes to MR 543.02 and regulation requirements will be provided by behavioral Health leadership to staff in inpatient behavioral health unit who assist with completing the Release of Information form 4/3/25--4/30/25. Education will be provided to staff through daily huddles and staff meetings focusing on staff signature on the ROI form. Education will be validated by attendance logs.
4.Audits will be completed by BH nursing leadership or designee. The audit process will be in place by 4/14/25. All charts for patients admitted to inpatient BH unit will be audited for signed ROI form. Audits will include signature of patient and signature of staff member including date/time. Audits will occur until 100% compliance for three consecutive months is achieved, then transition to random audits as needed. Results of audits will be shared by BH nursing leadership during the monthly Quality and Regulatory meeting.
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