Observations
The Nursing summaries provide a detailed review of the patient's history, however the summary should also provide the nurse's evaluation/impression of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the patient's current situation.
|
Plan of Correction
Nursing staff was orientated to the new format and was given examples of information for a Psychosocial Evaluation Summary upon admission for detoxification. The format
was inclusive of the Nurse's evaluation/impression of the individual demeanor, family dynamics,
support for recovery, Strengths and weaknesses that will either deter or benefit the client in the recovery process. Admission Psychosocial summaries will be monitored by Clinical Program Manager with each new admission to assure compliance with new format.
|
Observations
The facility's "Authorization to release medical information " form includes the following statements:
At the top of the form it states "I authorize and request the Meadville Medical Center, and the physicians who attend me, to release the medical information necessary for pre-certification of my hospital stay and the release of the medical information necessary for processing and billing my hospital stay to my appropriate third party payor."
Under the Medicare patient certification paragraph it states "....... I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim......."
These statements are considered general consents to release information. This form was found in all patient records reviewed. General consents to release information are specifically prohibited at 42 CFR Part 2, Subpart C, Subsection 2.32 and are indirectly prohibited at 42 CFR Part 2, Subpart C, Subsection 2.31 and at 71 P.S. subsection 1690.108(b) and 28 Pa. Code Subsection 157.23(b) as it refers to 4 Pa. Code subsection 255.5.
Also out of eight records reviewed, four (client records 5, A, B, and C) had consents to release information for the Medical Assistance office that included labwork, three (client records 1, 2, and 3) had consents to release information to the Single County Authority that included medication list, history and physical, labwork and consulting reports, and client record C had a PCPC summary (used for MA billing) that included the client's use history, vitals, BAC levels, and drug screen results.
These consents, which are being utilized for billing purposes, are to be restricted by 4 Pa. Code 255.5 which states:
Information released to judges, probation or parole officers, insurance company, health or
hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4), (7), (8) or subsection
(a) of this section, is for the purpose of determining the advisability of continuing the client with
the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) Client ' s prognosis.
(3) The nature of the project.
(4) A brief description of the client ' s progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the
frequency of such relapse.
|
Plan of Correction
The facility form " Authorization to Release Medical Information" has been revised as follows:
" I authorize and request the Meadville Medical Center,and the physicians who attend me, to release the medical
information necessary for pre-certification of my hospital
stay and the release of the medical information necessary for processing and billing my hospital stay to my appropriate third party payor with the exception of Drug and Alcohol admissions. A separate consent will be obtained on the unit upon admission
to comply with mandated Federal Regulations 42 CFR, Part II,Subpart C and provisions of 4 PA Code 255.5.
Under the Medicare patient certification paragraph reads:
" I authorize any holder of medical or other information about me to
release to the Social Security Administration or its intermediaries or
carriers any information needed for this or a related Medicare claim
with the exception of Drug and Alcohol admissions. A separate
consent will be obtained on the unit upon admission to comply with
mandated Federal Regulations 42 CFR, Part II and provisions of 4 PA Code 255.5.
The form revisions will be sent to the Forms Committee for approval after
consultation with our legal representation.
Charts will be monitored each week at Multi-disciplinary Meeting by the
Clinical Program Manager for compliance.
Instruction and discussion has taken place with all staff and an nformational
sheet has been given to each on Chapter 709, Subchapter C. General Standards & Interpretive
Guidelines inclusive of 28 PA Code 709.28 Confidentiality and Chapter 255.5 State Plan of the Prevention, Treatment and Control of Drug and Alcohol Abuse by the Clinical Program Manager.
General Consent samples have been put in place for staff to follow to comply with 4PA Code 255.5, when releasing information to insurance companies,
health or hospital plan or governmental officials ,judges, probation or parole officers.
Instruction on PCPC summaries has been included.
General Consent samples have been restricted to the following:
(1)Whether the client is or is not in treatment.
(2) Client's prognosis
(3) The nature of the project.
(4)A brief description of the client's progress.
(5)A short statement as to whether the client has relapsed into drug
And alcohol abuse and the frequency of such relapse.
Monitoring of compliance will be done by Clinical Program Manager on a weekly basis at the Multi-disciplinary meeting for compliance.
|