Observations
Based on the review of patient records, the facility failed to ensure the security and maintenance of the confidentiality of all patient records in accordance with 42 CFR and
relating to confidentiality.
The findings include:
Fourteen patient records were reviewed July 10-12, 2013. Fourteen patient records were reviewed for compliance in accordance with state and federal confidentiality regulations.
Patient record # 1 contained documentation of referral information being sent without a consent to release information.
Patient record # 2 contained a consent for Children and Youth. The information to be released was documented as "recommendations" which is not specific information.
Patient record # 3 contained a consent to release information for a funder that did not include what specific information would be released. It also listed the prognosis as a the purpose of the consent to release information.
Patient record # 8 contained several consents to release information to a funding source that did not include what specific information would be released. The purpose was listed as "progress".
Patient record # 9 contained a consent to release information for a funder that did not include what specific information would be released.
Patient record # 10 contained a consent to release information to a funding source. The purpose listed was "progress".
In addition to consents to release information not being completed according to regulation, the facility also failed to ensure the information in the patient records belonged to the patient. Patient records # 10 and # 11 both contained the information belonging to another patient.
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Plan of Correction
Interim Clinical Director and Director of Nursing will conduct 4 In-Services during the week of 7/22/2013 to re-orient applicable staff about Confidentiality Standards and Consents.
Random chart audits by Director of Nursing, Assistant Director of Nursing, Clinical Director and Clinical Supervisors will assure ongoing compliance with this standard. Those who remain non-compliant will be placed on disciplinary action. |