Observations
Based on an interview with the Director of Clinical Services and the Chief Operating Officer, along with a review of the Confidentiality policy and the Client Rights, the facility failed to comply with federal regulation 42 CFR Part 2 as per Licensing Alert 03-22.The facility was in receipt of a written consent from the personal representative for the disclosure of a deceased resident's chart and the facility did not provide that deceased resident's chart as per the written consent.
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Plan of Correction
The facility acknowledges the deficiency cited under 42 CFR Part 2 and Licensing Alert 03-22 regarding the failure to release a deceased resident's chart despite having valid written consent from the personal representative. Upon identification of this issue, the facility immediately reviewed the consent to ensure it met all federal requirements under 42 CFR Part 2. The consent was verified as valid, and the requested records have now been released in full to the authorized personal representative.
To prevent recurrence, the facility has revised its Confidentiality Policy to include clear guidance on disclosures permitted under 42 CFR Part 2, specifically addressing requests involving deceased residents and their personal representatives. In addition, the facility has implemented a standardized procedure for processing all medical record requests to ensure timely and compliant responses. A tracking log has also been established to monitor all incoming requests, including the date received, status, and date fulfilled, to ensure accountability and prevent delays.
Furthermore, the facility has designated a Compliance/Privacy Officer responsible for reviewing and approving all disclosures related to 42 CFR Part 2 to ensure adherence to federal regulations. All clinical, administrative, and medical records staff have been re-educated on 42 CFR Part 2 requirements, Client Rights related to confidentiality, and proper handling of written consents, including those pertaining to deceased individuals. This training was completed on 4/16/2026 and will be incorporated into annual mandatory training as well as new employee orientation.
To ensure ongoing compliance, the facility will conduct monthly audits of record requests and disclosures. Audit findings will be reviewed by leadership, and any identified issues will result in immediate corrective action, including additional staff training if necessary.
All corrective actions related to this deficiency were completed on 4/16/2026. The individual responsible for ensuring continued compliance is the COO. |