Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent in two of seven client records.
Client #6 was admitted on October 31, 2022 and is currently an active client. There was a consent to release information signed by the client on October 31, 2022 that did not document a recipient. The recipient line was left blank.
Client #7 was admitted on June 30, 2022 and discharged on July 20, 2022. There was no documentation of a valid consent to release information to the funding source documented in client record #7. It was confirmed that the facility received payment for services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In reference to the observations for client's 6 and 7 regarding informed and voluntary consent, UPMC McKeesport will ensure that all staff are trained in the appropriate completion of and expectations regarding releases of information.
Current staff have been reeducated regarding the competencies concerning completion of and expectations for release of patient information.
All staff will continue to be trained regarding release of information competency as a part of new hire training and in an ongoing annual competency to be the responsibility of the program manager. |