INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted May 6, 2024 through May 7, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Malvern Institute for Psychiatric and Alcoholic Studies, Inc., 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:
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Plan of Correction
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709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review client records, the facility failed to document the specific information to be disclosed on a release of information form in one of fourteen client records reviewed.
Client #4 was admitted to the residential level of care on August 24, 2023 and was discharged on September 14, 2023. The release of information form to an emergency contact was signed and dated by the client on August 24, 2023, but the release form indicated the "entire record" to be released, which is not specific to the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Identification of Failure: Staff were operating with the assumption that they could use the "entire record" check box on the release of information forms.
Action: Staff were educated that they assist the patient in selecting each item to be released individually. The EMR was modified, and the 'entire record' checkbox has been removed.
Monitoring: Monitoring will be completed monthly by the clinical supervisors/designated staff and monitored by the Director of PI during monthly chart audits to establish compliance with selecting each item identified by the patient for release on the release of information forms in the EMR. 25 charts will be audited each month with a goal of 100% compliance for 3 months. |