Observations
Based on conversations with the facility director and the counselor, the facility failed to maintain the security of patient identity information.
The findings include:
On May 2, 2014, a current patient list and a discharged patient list was requested. In a telephone conversation with the facility director who was off site, it was reported the lists were with the facility director but would be sent electronically to facility.
Patient grievances were requested and provided. Several hours later, the outcome of the grievances were provided and were not original copies. Per the counselor, the originals were with the facility director who was off site.
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Plan of Correction
The facility failed to maintain a copy of the patient master spreadsheet, including a current patient list and a discharged patient list, on-site at the facility. Furthermore, the facility failed to maintain copies of patient grievances and grievance committee meeting minutes in the same 3-ring binder. In accordance with 42 CFR 2.22 and § 709.28, the facility director will ensure ongoing compliance through regular maintenance of a secure copy of the patient master spreadsheet within the protected network on Polaris Renewal Services Administrative Assistant's computer. The Director shall also maintain copies of patient grievances and grievance committee meeting minutes in the same 3-ring binder in the Director's office, on-site at the facility. |