HospitalInspections.org

Based on record review and interview, the facility failed to provide individualized consent forms for Release of Information (ROI) to 11 of 11 (P1 through P11) patients sampled. This deficient practice has the likelihood to release patient information to unauthorized individuals. The findings are:

A. Record review of medical record for P1 through P11 revealed:

1. Record review of medical record for P1, discharge date: 04/30/21, No Release of Information (ROI) present on chart, case management note dated 04/29/21 confirms referrals made to two separate Skilled Nursing Facilities (SNF), no ROI obtained.

2. Record review of medical record for P2, discharge date: 06/21/21, No Release of Information (ROI) present on chart, case management note dated 06/18/21 confirms referrals made to a SNF, no ROI obtained.

3. Record review of medical record for P3, discharge date: 04/24/21, No Release of Information (ROI) present on chart, case management note dated 04/23/21 confirms referrals made to a SNF, no ROI obtained.

4. Record review of medical record for P4, discharge date: 04/26/21, No Release of Information (ROI) present on chart, case management note dated 04/26/21 confirms referrals made to a SNF, no ROI obtained.

5. Record review of medical record for P5, discharge date: 07/22/21, No Release of Information (ROI) present on chart, case management note dated 07/25/21 confirms referrals made to SNF, no ROI obtained.

6. Record review of medical record for P6, discharge date: 04/01/21, No Release of Information (ROI) present on chart, case management note dated 04/01/21 confirms referrals made to a SNF, no ROI obtained.

7. Record review of medical record for P7, discharge date: 08/03/21, No Release of Information (ROI) present on chart, case management note dated 08/02/21 confirms referrals made to two separate SNF, no ROI obtained.

8. Record review of medical record for P8, discharge date: 05/09/21, No Release of Information (ROI) present on chart, case management note dated 04/28/21 confirms referrals made to a SNF, no ROI obtained.

9. Record review of medical record for P9, discharge date: 04/13/21, No Release of Information (ROI) present on chart, case management note dated 04/09/21 confirms referrals made to a SNF, no ROI obtained.

10. Record review of medical record for P10, discharge date: 04/15/21, No Release of Information (ROI) present on chart, case management note dated 04/15/21 confirms referrals made to a SNF, no ROI obtained.

11. Record review of medical record for P11, discharge date: 06/04/21, No Release of Information (ROI) present on chart, case management note dated 06/03/21 confirms referrals made to a SNF, no ROI obtained.

A. Record review of facility document titled: "Patient Rights and Responsibilities", undated, bullet point 21, "As a patient you have the right to: The following in regards to your medical records and health information", fourth -, "The right to confidentiality and to information about how and/or when the facility may use or share your health information."

B. On 10/6/2020 at 3:30 pm during an interview with S(Staff) #8 (Case Management Manager) confirmed, "In May of 2021 we started utilizing a form for Release of Information but it has not been used and I don't have a copy of it. Up to that point information about the referral is written in the case management note. There are no ROI forms for the patient records reviewed"