INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2007 through September 28, 2007 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 October 26, 2007.
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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 client records it was determined that in four of four active client records and three of three discharged client records reviewed on September 27, 2007 and September 28, 2007 the facility failed to maintain patient confidentiality by releasing information in excess of 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 will receive
training in confidentiality, including
the limits of disclosure. Medical
records will be monitored.
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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
Five of five active patient files reviewed on September 27, 2007 and September 28, 2207 failed to protect patient confidentiality by releasing information in excess of the limitations imposed at 4 Pa. Code subsection 255.5(b) to Community Behavioral Health, Medicare, The Department of Public Welfare and the Behavioral Health Service Initiative.
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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 will receive
training in confidentiality, including
the limits of disclosure. Medical
records will be monitored.
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711.53(a)(7) LICENSURE Follow-up Information
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of client records it was determined that in three of five discharged client records reviewed on September 28, 2007 the facility failed to include documentation of patient follow-up services within seven days of the discharge date as required by hospital procedures.
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Plan of Correction
Policy #4500.015, Follow Up, will be revised by the Vice President for Health Affairs to reflect current and consistent practice. All programs will utilize standard procedures and format to complete and document follow up. A training outline for staff completing the follow up will be developed by the program directors. This training outline will be utilized by the program directors to train current and future staff responsible for follow up. Documentation of follow up will be monitored through monthly medical record reviews completed by the program directors. |
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 client records it was determined that in seven of seven active client records reviewed on September 27, 2007 and September 28, 2008 the facility failed to protect patient confidentiality by releasing information in excess of the limitations imposed at 4 Pa. Code subsection 255.5(b) to Community Behavioral Health, Medicare, the Department of Public Welfare and the Behavioral Health Service Initiative.
|
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 will receive
training in confidentiality, including
the limits of disclosure. Medical
records will be monitored.
|