INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 13, 2009 through July 16, 2009 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 14, 2009.
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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
Based on a review of patient records and an interview with staff the hospital failed to maintain confidential patient records as required in 4 Pa. Code Subsection 255.5(b) and limit the release of patient information to the patients presence in treatment, the nature of treatment, patient progress, patient prognosis, and a short statement regarding patient relapse with regard to releases of information made to judges, probation and parole, insurance companies, health or hospital plans or government officials.
Findings:
Six of six patient records reviewed on July 14, 2009, documented consents to release information to either insurance organizations, probation and parole, government entities and the judicial systems. Information released to government officials and health plans in the six of six patient records reviewed included drug and alcohol histories, laboratory analysis results, psychiatric evaluations, treatment plans, progress notes, discharge plans and discharge summaries. Information released to the judicial system included the patients medical history, physical examination, psychiatric evaluation, and progress notes.
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Plan of Correction
1. 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. This is ongoing. Eagleville Hospital's program and department directors are responsible for achieving and maintaining compliance with this standard.
2. Eagleville Hospital staff will be re-educated on PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure. The chief privacy officer has developed an online educational training for staff to complete. All staff responsible for releasing confidential information will complete this training by August 21, 2009.
3. The release of information consents will be reviewed and revised as appropriate to ensure PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure are met. This item will be completed by August 21, 2009.
4. Medical records will be monitored by the director of medical records.
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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
Based on a review of patient records and an interview with staff, the hospital failed to maintain confidential patient records as required in 4 Pa. Code subsection 255.5(b) and failed to limit the release of patient information to the patients presence in treatment, the nature of treatment, patient progress, patient prognosis, and a short statement regarding patient relapse to judges, probation, parole, insurance company, health or hospital plan or government officials.
Findings:
Twelve of twelve patient records reviewed on July 15, 2009 and July 16, 2009 failed to limit the specific information disclosed to the patient's prognosis (including diagnosis), presence in treatment, the nature of the project nature, a brief description of the client's progress and the frequency of relapse. Information in twelve of twelve patient records reviewed provided documentation of the release of patient information to government officials and health plans. Information released to both government officials and health plans included drug and alcohol histories, laboratory results, psychiatric evaluations, treatment plans, progress notes, discharge plans and discharge summaries. Information released to the judicial system included the patients' medical history, physical examination, psychiatric evaluation and progress notes.
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Plan of Correction
1. 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. This is ongoing. Eagleville Hospital's program and department directors are responsible for achieving and maintaining compliance with this standard.
2. Eagleville Hospital staff will be re-educated on PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure. The chief privacy officer has developed an online educational training for staff to complete. All staff responsible for releasing confidential information will complete this training by August 21, 2009.
3. The release of information consents will be reviewed and revised as appropriate to ensure PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure are met. This item will be completed by August 21, 2009.
4. Medical records will be monitored by the director of medical records.
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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
Based on a review of patient records and an interview with staff, the hospital failed to maintain confidential patient records as required in 4 Pa. Code Subsection 255.5(b) and failed to limit the release of patient information to the patients presence in treatment, the nature of treatment, the patients' progress in treatment, the patients' prognosis (including the diagnosis), and a short statement regarding the patients' relapse relative to releases of information to judges, probation and parole officers, insurance companies, health or hospital plans or government officials.
Findings:
Twelve of twelve patient records reviewed on July 15, 2009 and July 16, 2009 failed to identify the specific information disclosed to the patients' prognosis (including the diagnosis), The patients' presence in treatment, the nature of the project, a brief description of the patients' progress in treatment, and the frequency of relapse. Information in twelve of twelve records reviewed provided documentation of releases of information to government officials and health plans. Information released to both government officials and health plans included drug and alcohol histories, laboratory results, psychiatric evaluations, treatment plans, progress notes, discharge plans and discharge summaries. Information released to the judicial system included the patients' medical history, physical examination, psychiatric evaluation, and progress notes.
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Plan of Correction
1. 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. This is ongoing. Eagleville Hospital's program and department directors are responsible for achieving and maintaining compliance with this standard.
2. Eagleville Hospital staff will be re-educated on PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure. The chief privacy officer has developed an online educational training for staff to complete. All staff responsible for releasing confidential information will complete this training by August 21, 2009.
3. The release of information consents will be reviewed and revised as appropriate to ensure PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure are met. This item will be completed by August 21, 2009.
4. Medical records will be monitored by the director of medical records.
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