Observations
Based on the review of client records, the facility failed to comply with 4 Pa. Code 255.5 relating to projects and coordinating bodies: disclosure of client-oriented information, in seven of seven records.
The findings include:
On October 17, 2011, seven client records were reviewed for consents to release information and client related correspondences, specifically records # 1, 2, 3, 4, 5, 6 and 7. All seven records reviewed, contained consent to release information forms that did not include a statement informing the client of his right to verbally revoke the consent releasing information. The facility documented that the client must revoke the consent in writing.
Additionally, in four of the seven records, the consent to release information form included a statement that permitted the facility to act in reliance on the client ' s verbal consent to release information.
Client # 1 was admitted on 7/25/11. A release form disclosing information to Gaudenzia dated 7/28/11 did not include a statement informing the client of his right to verbally revoke the consent. The facility documented that the client must revoke the consent in writing. Additionally, this consent to release information form included a statement that permitted the facility to act in reliance on the client ' s verbal consent to release information.
Client # 2 was admitted on 9/4/11. A release form disclosing information to the client ' s primary care physician dated 9/6/11 did not include a statement informing the client of his right to verbally revoke the consent. The facility documented that the client must revoke the consent in writing.
Client # 3 was admitted on 7/21/11. A release form disclosing information to Gaudenzia dated 7/27/11 did not include a statement informing the client of his right to verbally revoke the consent. The facility documented that the client must revoke the consent in writing. Additionally, this consent to release information form included a statement that permitted the facility to act in reliance on the client ' s verbal consent to release information.
Client # 4 was admitted on 7/18/11. A release form disclosing information to Gaudenzia dated 7/21/11 did not include a statement informing the client of his right to verbally revoke the consent. The facility documented that the client must revoke the consent in writing. Additionally, this consent to release information form included a statement that permitted the facility to act in reliance on the client ' s verbal consent to release information.
Client # 5 was admitted on 8/30/11. A release form disclosing information to the client ' s primary care physician dated 9/7/11 did not include a statement informing the client of his right to verbally revoke the consent. The facility documented that the client must revoke the consent in writing.
Client # 6 was admitted on 7/25/11. A release form disclosing information to the client ' s primary care physician dated 9/29/11 did not include a statement informing the client of his right to verbally revoke the consent. The facility documented that the client must revoke the consent in writing.
Client # 7 was admitted on 6/20/11. A release form disclosing information to an insurance company dated 6/26/11 did not include a statement informing the client of his right to verbally revoke the consent. The facility documented that the client must revoke the consent in writing. Additionally, this consent to release information form included a statement that permitted the facility to act in reliance on the client ' s verbal consent to release information.
An interview with the facility director on October 17, 2011 confirmed the findings.
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Plan of Correction
An In-Service Training was conducted with all staff, including GHWC Medical Staff, on the 1st of November. During the In-Service Training, all old forms were collected and discarded due to the fact that out of compliance with the Confidentiality policy.
At that time, all staff were given the new forms and instructed to only utilize the new/revised forms, which contains the specified verbiage that is in accordance with 709.28 (C) Confidentiality policy.
In order to prevent the reoccurrence of this citation, the Nurse Manager from 1306 Spring Garden and Eastern Region Health Services Consultant will conduct monthly audits of the medical records to ensure that the appropriate consent forms are completed and in accordance with the 709.28 (C) Confidentiality policy.
For clinical charts, Clinical Supervisor will conduct monthly audits of the charts. During that audit, Clinical Supervisor will ensure that consent forms are appropriately completed and in accordance with the 709.28 (C) Confidentiality policy.
Finally, the Clinical Supervisor and the identified Medical Personnel (Nurse Manager from 1306 Spring Garden and the Eastern Region Health Services Consultant) will report all findings of those perspective audits to the Program Director of GHWC. Program Director will also ensure that monthly audits are taking place and any corrections needed to the consents, due to non-compliance with the abovementioned policy will be rectified immediately.
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Observations
Based on the review of client records, the facility failed to document a physical examination to include the physician ' s overall impression of the client, as per facility policy, in seven of seven client records.
The findings include:
On October 17, 2011, physical examinations were reviewed in seven client records, specifically records # 1, 2, 3, 4, 5, 6 and 7. The facility did not document physical examinations to include the physician's overall impression in client records # 1, 2, 3, 4, 5, 6 and 7.
The facility ' s policy titled " PHYSICAL EXAMINATION LABORATORY STUDIES " states:
" Documentation of the results of the physical examination shall include but not be limited to: evidence of injury, neurological findings, investigation of the organ systems for potential infectious disease, pulmonary, liver and cardiac abnormalities, dermatological squeal of addiction, vital signs, examination of general appearance, head, ears, eyes, nose, throat, chest, abdomen, extremities, skin assessment, concurrent problems and the physician's overall impression of the client. "
Client # 1 was admitted on 7/25/11. The physical examination in client # 1 ' s record dated 7/28/11 did not include the physician ' s overall impression of the client.
Client # 2 was admitted on 9/4/11. The physical examination in client # 2 ' s record dated 9/9/11 did not include the physician ' s overall impression of the client.
Client # 3 was admitted on 7/21/11. A physical examination was required to be completed by 7/28/11, but the physical examination in client # 3 ' s record was dated 9/7/11. Additionally, the physical examination did not include the physician ' s overall impression of the client.
Client # 4 was admitted on 7/18/11. A physical examination was required to be completed by 7/25/11, but the physical examination in client # 4 ' s record was dated 7/28/11. Additionally, the physical examination did not include the physician ' s overall impression of the client.
Client # 5 was admitted on 8/30/11. A physical examination was required to be completed by 9/6/11, but at the time of review, client # 5 ' s record did not contain a physical examination.
Client # 6 was admitted on 7/25/11. A physical examination was required to be completed by 8/1/11, but at the time of review, client # 6 ' s record did not contain a physical examination.
Client # 7 was admitted on 6/20/11. The physical examination in client # 7 ' s record dated 6/27/11 did not include the physician ' s overall impression of the client.
An interview with the facility director on October 17, 2011 confirmed the findings.
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Plan of Correction
A meeting took place on the 19th of October with Program Director, Medical Director, and the Eastern Region Health Services Consultant. During that meeting, the doctor was informed of the citation issued to the facility. Director and Eastern Region Health Services Consultant shared with Doctor that he needed to expound on responses and impressions to include the identified areas within this citation.
To ensure that this deficiency does not reoccur, the Eastern Region Health Services Consultant has devised and implemented a continuous quality improvement measure. This measure/system includes the following:
Eastern Region Health Services Consultant, who will be directly supervising the Medical Director, will meet with Medical Director once a month. Prior to that meeting, Eastern Region Health Services Consultant will randomly identify a client that came into GHWC during the past month and request that the Medical Director bring a copy of the completed physical to be reviewed during their supervision. Medical Director and Eastern Region Health Services Consultant will review the physical to evaluate its completeness to ensure that the impressions are in compliance and completed in a quality fashion.
Finally, it will be the responsibility of the Eastern Region Health Services Consultant to ensure that this system is continuously implemented and follow to ultimately decrease non-compliance with policy 709.51. It will also be the responsibility of the Eastern Region Health Services Consultant to communicate any deficiencies/challenges to the Program Director.
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