INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 20, 2006.
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Plan of Correction
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709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
The document used by the facility to demonstrate that employees are informed of their rights was consistently missing from the personnel records and was not documented elsewhere.
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Plan of Correction
As part of the hiring process, all new staff are given an Employee Handbook which contains information about Employee Rights. However, the handbook did not contain information regarding our policy of employee's right to review their personnel file. On 5/26/06 Roxbury's Human Resource Coordinator drafted a verification form that all new hires will sign to verify that they have received a copy of this policy and to demonstrate that they have been made aware of Employee Rights. This document was reviewed by the Licensing Specialist during the site visit and the form was put into use at that time. On 6/13/06 this Employee Rights policy, the sign-off form and a new copy of the Employee Handbook were circulated to all current staff. Staff returned the verification forms and the HR Coordinator put them in all existing personnel files. A copy of this form is being submitted as part of this POC. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
1.) Consents to release information were not signed prior to the disclosure of information in charts #3 & #5.
2.) The specific information to be released section of the consent to release information form included the term "discharge information" as an option. This term does not describe the specific information to be released.
3.) The specific information to be disclosed, as it was listed on some of the consent to release information forms, failed to inform the client to whom it pertained what information was actually being released. The counselor was not completing the form correctly.
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Plan of Correction
1) Staff training on confidentiality was held by the facility Risk Manager on 6/15/06. Attendance at a DOH-sponsored IRETA workshop on Confidentiality will be added to annual training plans of identified counselors. Director of OP will be responsible to monitor appropriate release of information practices in the OP Dept. through record audits and supervision.
2) Master copies of the current Consent to Release Information forms -- which include appropriate language -- will be circulated. All patient care department staff and OP staff will be instructed to destroy obsolete versions. Director of Outpatient will monitor use by OP staff and will implement by 6/16/06.
3) Staff training on confidentality was held by the facility Risk Manager on 6/15/06 and proper form protocol will be reinforced at weekly OP staff meeting. Utilizing most recent version of Consent to Release Information form, Director of OP will assure compliance with standard through medical record audits. |