Observations
The facility failed to document an informed and voluntary consent from the patient prior to the disclosure of information to the funding entity for treatment authorization in one of seven detoxification patient records reviewed on October 29 - 30, 2018.
Patient # 8 was admitted October 16, 2018 and discharged October 25, 2018. The disclosure occurred on October 16, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consent obtained from this patient, patient was in level 4B at this time. Consent signed on 10/30/2018. Patient had originally signed release for his medical managed care for PA Medical Assistance in Allegheny county, but staff had neglected to have him sign for his behavioral health managed care. Original demographics sheet from ED registration reflected the medical managed care. Newer staff RN was not aware that patient behavioral health managed care covered the reviews of this stay. Staff re-oriented, preceptors for new staff made aware to monitor these, and email as well as grid composed revealing which managed cares, both medical and behavioral health, would need to be obtained upon patient admission. Program Supervisor and night shift nursing staff will monitor all admissions for the proper releases on ongoing basis and as on-call person, Program Supervisor will continue to coach all staff on proper consents. |