Observations
Based on the review of the policy and procedures manual and an interview with the facility director, the facility failed to document written procedures for staff to follow in case of an emergency which included notifying the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
The findings include:
The policy and procedure manual was reviewed on March 28, 2011. The facility did not document written procedures for staff to follow in case of an emergency which included notifying the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
The facility director was interviewed on March 28, 2011 and confirmed there were no written procedures for staff to follow in case of an emergency that included notifying the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
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Plan of Correction
The Safety Officer of the Stairways Behavioral Health Compliance Department was notified by the facility director of the requirement of General Safety and Emergency Procedures (705.27 (4)(ii)) regulations for PA Drug and Alcohol programs on 3/28/11. A policy has been written to document the procedures for staff to follow in case of an emergency which include notifying the Department within 48 hours of a fire, other disaster or situation which affects the continuation of services.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document an informed and voluntary consent from the client for the disclosure of information which informed the client that the facility must accept verbal revocations of consent to release information. The consents to release information contained in five of five client records failed to inform the clients that the facility was required to accept their verbal revocation of consent.
The findings include:
Ten client records were reviewed on March 28-29, 2011. Five client records were required to include documentation of an informed and voluntary consent from the client for the disclosure of information contained in the client record. The facility did not document informed and voluntary consents for the disclosure of information in client records # 1, 3, 4, 5 and 6 which informed the clients that the facility was required to accept their verbal revocations of consent.
Client # 1 was admitted on October 27, 2010. Informed and voluntary consents signed by the client on October 27, 2010 contained the following statements: I understand that this consent can be cancelled at any time, upon my written request. I understand that in order to revoke this authorization, it must be in writing to Stairways Behavioral Health. These statements are in violation of 42 CFR Part 2, Subpart C, The facility must accept a client's verbal revocation of a consent.
Client # 3 was admitted on December 8, 2010. Informed and voluntary consents signed by the client on December 8, 2010 contained the following statements: I understand that this consent can be cancelled at any time, upon my written request. I understand that in order to revoke this authorization, it must be in writing to Stairways Behavioral Health. These statements are in violation of 42 CFR Part 2, Subpart C, The facility must accept a client's verbal revocation of a consent.
Client # 4 was admitted on January 4, 2011. Informed and voluntary consents signed by the client on January 4, 2011 contained the following statements: I understand that this consent can be cancelled at any time, upon my written request. I understand that in order to revoke this authorization, it must be in writing to Stairways Behavioral Health. These statements are in violation of 42 CFR Part 2, Subpart C, The facility must accept a client's verbal revocation of a consent.
Client # 5 was admitted on November 1, 2010. Informed and voluntary consents signed by the client on November 1, 2010 contained the following statements: I understand that this consent can be cancelled at any time, upon my written request. I understand that in order to revoke this authorization, it must be in writing to Stairways Behavioral Health. These statements are in violation of 42 CFR Part 2, Subpart C, The facility must accept a client's verbal revocation of a consent.
Client # 6 was admitted on December 8, 2010. Informed and voluntary consents signed by the client on December 8, 2010 contained the following statements: I understand that this consent can be cancelled at any time, upon my written request. I understand that in order to revoke this authorization, it must be in writing to Stairways Behavioral Health. These statements are in violation of 42 CFR Part 2, Subpart C, The facility must accept a client's verbal revocation of a consent.
The facility director was interviewed on March 29, 2011 and confirmed that the facility's standard consent to release information forms included the revocation of consent statement requiring that the client submit a written revocation and failed to inform the client that the facility was required to accept the clients' verbal revocations of consent.
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Plan of Correction
The Compliance Officer of the Stairways Behavioral Health Compliance Department was notified by the facility director of the requirements of confidentiality regulation in PA Drug and Alcohol programs on 3/28/11 (709.28(c)). The release of information has been edited to comply with 42 CFR, Part 2, Subsection C, 2.31 (c)(3) to include a statement of exemption for the ability of clients involved with Drug and Alcohol programs to be able to revoke the release of information verbally. |