Observations
Based on a review of patient records, the facility failed to obtain consent to release information forms for funding sources in three of three patient records reviewed.
The findings include:
Seven patient records were reviewed on June 20, 2013. Three records were reviewed for consent to release of information forms. Three of three records, # 2, 3, and 4, did not include consent to release information forms for the funding source.
The findings were reviewed with the facility director and the counselor and were not disputed.
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Plan of Correction
H127
1.) Warren General Hospital Detoxification Staff and support staff will complete written authorization on all clients for the purpose of payment from 3rd party payers, managed care organizations and others, as required in PA Regulation 4 Pa. 4 Pa. Code 255.4 and 255.5.
2.) From the date of this survey, June 20, 2013 onward, Warren General Hospital Detoxification Staff and support staff have ensured that PA Regulation 4 Pa. Code 255.5 (b) has been followed. All clients since that date have signed appropriate consents for disclosure of information to 3rd party payers, managed care organizations and others.
3.) Warren General Hospital Detoxification Staff and support staff will be re-educated by the Facility Director on PA Regulation 4 Pa. 4 Pa. Code 255.4 and 255.5 and limits of disclosure in a staff meeting held on 7/24/13. All Hospital Detoxification Staff and support staff will be required to sign a document stating that they have been educated and acknowledge the need for written authorization, knowledge of particular information permitted to be released, and the terms of release pursuant to PA Regulation 4 Pa. Code 255.5 (b) and limits of disclosure.
4.) During the last week of each month, the Facility Director or designee will Audit 15 Medical Records per month to ensure that the records are in compliance with PA Regulation 4 Pa. 4 Pa. Code 255.4 and 255.5
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