Observations
The findings:
Eight client records were reviewed on July 12, 2016 for informed and voluntary consent to release information forms.
Client records #1-8 did not contain consent to release information forms for the laboratory where the client's urinalysis was sent. Additionally, the facility did not have a qualified service organization agreement (QSOA) witht the laboratory. Client records #1-8 had documentation showing that the facility had correspondences with the laboratory relative to each of the clients' urinalyses.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
"To remedy the incident, effective August 3rd, 2016, Presbyterian Outpatient entered into a Qualified Service Organization/Business Associate Agreement (QSA) with its contracted Diagnostic Laboratories (ADL). To ensure that such incidents do not recur, this QSA is on-going and the Program Director will maintain current documentation in the Presbyterian Outpatient's Policy and Procedure Manual. An annual review of Policy and Procedures will take place and any necessary updates to this QSA will be made at the time of review. Should a new laboratory be contracted, the same procedures will be implemented."
|