INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on October 28, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, BGI of Brandywine, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of the client's medical record and an interview with the medical records director, the facility failed to obtain an informed and voluntary consent from the client for the release of client related information.
The findings include:
A letter was sent out on September 16, 2013 addressed "To Whom It May Concern" with identifying information pertaining to the client. The information identified the individual as former client receiving drug and alcohol treatment services and the status of their participation. The facility failed to have a consent to release form on file to release this information.
An interview with the facility director and medical records director on October 28, 2013 confirmed the findings.
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Plan of Correction
Medical Records Director was retrained by the Executive Director on the standards related to this deficiency.
Medical Records Director then reoriented all Medical Records staff on this standard.
Expectations: NO letter will be sent from the facility adressed to "To whom it may concern." All letters will have a properly executed consent to release information form on file that ties back to any letter sent.
Medical Records Director did receive a written disciplinary action placed in her HR file for this deficiency.
Compliance will be maintained by Medical Records Director adding this item to the audit checklist done on 100% of closed charts. |