Observations
Based on a review of administrative documentation, the facility failed to allow a client the right to inspect their own records when requested.
Client # 1 was admitted on March 1, 2024, and discharged on March 6, 2024. This client was re-admitted on August 14, 2024, and discharged on September 5, 2024. A request for a copy of the client record was sent to the facility via the facility website. The facility did not provide the client record as requested.
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Plan of Correction
The Records Custodian will ensure that all medical record requests will be processed and fulfilled within 30 days of receipt of all required documentation, to include a fully completed and signed Release of Information. If there are any issues regarding required documentation, this will be clearly and promptly communicated to the requesting entity (when allowable). These requests will be tracked utilizing a centralized spreadsheet.
The Director of Regulatory Affairs & Compliance will review the spreadsheet on an at least monthly basis, and any noted concerns will be addressed with the Records Custodian for immediate correction. |