Observations
Based on a review of client records on October 2, 2020, the facility failed to document a completed consent to release information form prior to releasing information in client #'s 1 and 7.
Client #1 was admitted on August 20, 2020 and was still active at the time of the inspection. A fax was sent to a medical facility on September 16, 2020 without a consent form.
Client #7 was admitted on March 12, 2020 and was discharged on August 15, 2020. A fax was sent to a medical facility on August 6, 20202 without a consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Saint John Vianney Center will obtain written consent prior to releasing resident information.
-The Director of Quality & Regulatory Compliance will complete a review of confidentiality policies and make revisions as needed.
-The Director of Quality & Regulatory Compliance will facilitate a procedure review with nursing staff by 11/20/2020. This review will include use of consent forms and need for written consent prior to release of information via fax.
-The Director of Quality & Regulatory Compliance will review a sample of active charts for compliance monthly by reviewing faxed communications and completed release of information forms present in the medical record. The results will be reported to the facility's Performance Improvement Committee monthly to provide on-going monitoring. Chart reviews will continue until six consecutive months of 100% compliance is achieved.
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