Observations
Based on a review of client records, the facility failed to document a valid consent to release information contained in the client record that is compliant with PA Code 255.5 in two of seven client records.Client #6 was admitted on January 16, 2022 and discharged on January 25, 2022. There was a signed consent to release information for the funding source documented on January 16, 2022; however, there was no recipient documented. There was an additional signed consent to release information documented on January 16, 2022, which had "none" written on the recipient line.Client #7 was admitted on November 17, 2021 and discharged on November 22, 2021. There was a signed release of information documented for the funding source on November 18, 2021; however, there was no recipient documented.It was confirmed with staff that verbal authorizations were conducted to obtain payment for services provided to these two clients. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility consent to release information for detox unit revised by hospital privacy officer ? 3/15/22
Revised consent to release information for detox unit approved by hospital forms committee ? 3/17/2022
Detox Unit Leader (Clinical Supervisor) will provide education/training in relation to completion of Request of Information consents This education will be completed by 4/4/2022 with 100% of all Detox staff.
Weekly 10 charts will be audited by Detox Unit Leader for completed Request of Information consents. These audits will be done weekly until 100% compliance attained for four weeks. Once 100% compliance attained for four weeks, audits will commence on a monthly basis of 10 charts per month to ensure compliance. Any non-compliance will immediately be addressed by Detox Unit Leader (Clinical Supervisor).
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