Observations
The facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in one of seven patient records reviewed.
Client #4 was admitted on November 15, 2017 and was discharged on February 21, 2018. There was a facsimile sent to another agency on February 1, 2018; however, there was no consent to release information documented in the record prior to the disclosure.
Client #7 was admitted on March 28, 2018 and was discharged on May 2, 2018. There was a facsimile sent to another agency on April 23, 2018; however, there was no consent to release information documented in the record prior to the disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will receive training on Pa Code 255.5, Federal code 42 C.F.R. and § 709.28. Confidentiality. Training will be completed by 10/1/18, project manager is responsible. Going forward, project manager will inspect all files to insure proper paperwork is in place. |