INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 2008 through July 25, 2008, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Eagleville Hospital was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on August 25, 2008.
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Plan of Correction
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157.23 (b) LICENSURE Patient records.
157.22 Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects and coordinating bodies: disclosure of client-oriented information).
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Observations
The hospital detoxification activity failed to keep patient records confidential in accordance with 4 Pa. Code subsection 255.5(b).
Findings
Six of six detoxification records reviewed on July 23, 2008 and July 25, 2008, documented the release of excessive information to insurance organizations. Excessive information released to insurance organizations in the patient records reviewed include laboratory test results, psychiatric evaluations, treatment plans, progress notes, medical and counseling discharge summaries which exceed the limitations imposed at 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
Eagleville Hospital continues to educate 3rd party payors, managed care organizations and others, as appropriate, on PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure. Eagleville Hospital's program and department directors are responsible for achieving and maintaining compliance with this standard. All employees receive training in confidentiality, including the limits of disclosure. Medical records will be monitored. |
711.62(c)(2)(ii) LICENSURE Specific Information Disclosed
711.62. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
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Observations
The non-hospital detoxification facility failed to limit release of client related information to insurance organizations to the limitations imposed at 4 Pa. Code Subsection 255.5(b).
Findings:
Seven of seven detoxification records reviewed on July 23, 2008 and July 25, 2008, documented the release of excessive information to insurance organizations. Excessive information released to insurance organizations in the patient records reviewed include laboratory test results, psychiatric evaluations, treatment plans, progress notes, medical and counseling discharge summaries.
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Plan of Correction
Eagleville Hospital continues to educate 3rd party payors, managed care organizations and others, as appropriate, on PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure. Eagleville Hospital's program and department directors are responsible for achieving and maintaining compliance with this standard. All employees receive training in confidentiality, including the limits of disclosure. Medical records will be monitored. |
711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
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Observations
The non-hospital treatment and rehabilitation facility failed to limit release of client related information to insurance organizations in accordance with the limitations imposed at 4 Pa. Code Subsection 255.5(b)..
Findings:
Seven of seven client records reviewed on July 23, 2008 and July 25, 2008, documented the release of excessive information to insurance organizations. Excessive information released to insurance organizations in the records reviewed include laboratory test results, psychiatric evaluations, treatment plans, progress notes, medical information and counseling discharge summaries.
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Plan of Correction
Eagleville Hospital continues to educate 3rd party payors, managed care organizations and others, as appropriate, on PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure. Eagleville Hospital's program and department directors are responsible for achieving and maintaining compliance with this standard. All employees receive training in confidentiality, including the limits of disclosure. Medical records will be monitored. |