Observations
Based on the review of client records, the facility failed to document that the client was informed of right to inspect his/her own records which included that the project director may temporarily remove portions of the record, prior to the inspection by the client, if the director determines that the information may be detrimental if presented to the client and that the reasons for removing sections shall be documented and kept on file, in five of five client records.
The findings include:
Nine client records were reviewed on August 7, 2015. Five client records were reviewed as outpatient records and required documentation that the client was informed of the right to inspect his/her own record. There was no documentation in client records # 5, 6, 7, 8 and 9 that the client was informed of the right to inspect his/her own record.
Client # 5 was admitted on May 12, 2015 and discharged on July 7, 2015. There was no documentation that the client was informed of the right to inspect his/her own record.
Client # 6 was admitted on February 6, 2015 and discharged on May 7, 2015. There was no documentation that the client was informed of the right to inspect his/her own record.
Client # 7 was admitted on April 23, 2015 and discharged on July 27, 2015. There was no documentation that the client was informed of the right to inspect his/her own record.
Client # 8 was admitted on March 3, 2015. There was no documentation that the client was informed of the right to inspect his/her own record.
Client # 9 was admitted on April 2, 2015. There was no documentation that the client was informed of the right to inspect his/her own record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Patient handouts were amended to include the information of access to his/her own medical record with the following addition:
"According to laws of the Commonwealth of Pennsylvania PA Department of Drug and Alcohol Programs Division of Program Licensure 711.93(b)(1) LICENSURE, and Federal Regulations, 42 CFR, Part 2, Rules and Regulations for Hospitals, any client has the right to review his/her chart during treatment on the Stepping Stones Unit at Meadville Medical Center, or after discharge from that program.
1. Access to medical records may be made through the appropriate staff member who will inform the Program Supervisor of the client?s wish to see his/her record, or by direct contact with Meadville Medical Center?s Medical Records Department. The Medical Records Department Manager is in charge of securing all records on discharged clients in accordance with confidentiality guidelines. The Medical Records department Manager may consult with Stepping Stones Program Supervisor when there has been a request to view records, to insure compliance with confidentiality guidelines.
2. The chart always remains the property of Meadville Medical Center.
3. The Project Director only may temporarily remove portions of the record prior to inspection by the client if she determines that the information may be detrimental if presented to the client. This determination may be made after consultation with the Medical Director, Program Supervisor or Nurse Manager. Reasons for removing sections shall be documented and kept on file."
The orientation to treatment checklist had a line added for this handout information where the patient dates and initials each item that is reviewed and givent o patient, and then signs the entire document with witness by the counselor.
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