Observations
Based on a review of patient records, the facility failed to document a consent to release information form that included the name of the person, agency or organization to whom disclosure is made and the specific information disclosed in one of seven records.
Patient # 4 was admitted July 23, 2021 and discharged July 29, 2021. A consent for the funding entity dated July 23, 2021 did not include documentation of the name of the funding entity and the specific information disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Based on the findings related to this observation, a specific consent related to the 5-Points of release for funding entities will be utilized on all patients admitted to the facility. This document will contain the explicit name of the funding entity as required. Items released to said funding entity will be limited to the components outlined in 4 PA Code 255.5 (b). To ensure compliance with the 5-Point Consent Form, Project Director will oversee the completion of weekly spot audits to monitor proper form completion. Spot audits will begin during the week of 12/13/2021 and be conducted, at minimum, once/week on half the current census of the facility at the time of the audit. Monitoring will occur indefinitely or at reduced/increased intervals as decided by the project director of the program. Development of a formal audit tracer will begin on 12/13/21 with the UPMC quality management department. Education of staff on obtaining, filing, and storing the 5-Point Consent will occur as needed during daily huddles occurring at 0930 M-F. |