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Based on record review and interview, the facility failed to provide individualized consent forms for Release of Information (ROI) to 5 of 5 (P#1-P#5) 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 P#1-P#5 revealed:

1. P#1, admission date: 5/28/2020, No Release of Information (ROI) present on chart.
2. Discharge Instructions for P#1, appointment made with another medical provider, no ROI obtained.
3. P#2 admission date 5/30/2020, No ROI present on chart.
4. Discharge Instructions for P#2, appointment made with another behavioral health provider no ROI obtained.
5. P#3 admission date 5/21/2020, No ROI present on chart.
6, Discharge Instructions for P#3, appointments made with another medical provider, no ROI obtained.
7. P#4 admission date 9/29/2020, No ROI present on chart.
8. Discharge Instructions for P#4, appointments made with another behavioral health provider, no ROI obtained.
9. P#5, admission date: 10/5/2020, No ROI on chart. P#5 is still a current patient.


B. Review of facility policy titled "Behavioral Health Release of Information", dated 8/01/2020 states:
1. Patients are asked to complete the Release of Information (ROI) form listing those persons to whom information can be released. The form can be used for:
a) Family members and significant others.
b) Family physicians or other clinicians.
c) Referral sources such as Employee Assistance Programs (EAPs) or others such as employees.

The ROI form must be signed and dated by either the patient or legal guardian and by staff witness. The patient should read the statement above the signature, which explains briefly how his/her confidentiality rights, and how consents may be revoked. The completed form is retained in the patient record and is part of the permanent medical record.


C. On 10/6/2020 at 3:30 pm during an interview with S#9 (Patient Access Supervisor) confirmed, "at admission patients are offered to sign a Release of Information but they have the right to refuse so they may not have any signed ROI on chart at admission. Patients can sign a ROI at anytime during treatment if they authorize for information to be released."


D. On 10/6/2020 at 4:00 pm during an interview with S#2 (Assistant Nurse Manager), S#3 (Administrator), S#4 (Clinical Regulatory and Accreditation Quality), S#6 (Infection Preventionist), S#7 (Quality Manager), S#9 (Patient Access Supervision) confirmed, the staff was unable to answer the question of the need for ROI when making discharge appoints. S#11, LPCC (Licensed Professional Clinical Counselor) was contacted via phone. S#11 confirmed, "When calling for a discharge appointment there is no ROI needed because it is considered continuation of care and in general we do not get an ROI for making appointments."

Based on observation, record review and interview, the facility failed to employ methods for preventing and controlling the transmission of infections by not following the facility's infection control and prevention program. This deficient practice has the likelihood to expose patients to infectious diseases.

The findings are:

A. On 10/6/2020 at 9:15 am during observation, the state surveyors were not screened upon entry to the facility. After touring the facility for two and a half hours, S#2 (Administrator) asked the state surveyors if the screening was done at entrance, S#2 was informed no screening was performed prior to entry to the facility. S#2 asked the state surveyor to complete screening at that time. The surveyors were escorted back to the front of the building to be screened. S#1 (Nurse Manager) did not sanitize the thermometer used to take the temperatures of the surveyors and placed the thermometer in a container with other medical supplies. The answers to the screening questions and temperatures were not documented.

B. On 10/6/2020 at 9:54 am during an interview with S#13 (Tech) stated, face masks are worn by all staff the whole time they are on the unit. There is sufficient masks , gloves, hand hygiene supplies and supplies for cleaning on the unit. All staff received training on how to put on and remove masks and all equipment.

C. On 10/6/2020 at 10:10 am during an interview with S#12 (Registered Nurse) stated, there is plenty of Personal Protective Equipment (PPE) on the unit. All staff on the unit are required to wear a surgical mask from the time they enter the facility to the time they exit the facility, unless they are eating or drinking in the break room. All staff has been trained on mask usage and if I see someone without a mask I would politely ask them to put on their mask. "We want to protect our patients and each other".

D. On 10/6/2020 at 4:00 pm during observation of video tape for 100N (Unit at the facility) dated 9/28/2020 from 9:30 am to 11:45 am confirmed that S#19 (Registered Nurse) was not wearing a mask in patient care areas. S# 19 alternated between wearing and not wearing a mask throughout the observation.

E. On 10/6/2020 at 4:00 pm during an interview with S#2 (Assistant Nurse Manager), S#3 (Administrator) and S#15 (Security Manager) during review of the video recording of the workstation on 100N (Unit at the facility) confirmed, a staff member in the video was continuously removing their surgical mask. S#2 (Assistant Nurse Manager) also confirmed that the tech in the video has their mask hanging off their ear again and again. S#2 (Assistant Nurse Manager) stated, this is a practice that is inappropriate and will be addressed immediately.

F. Record Review of Facility Infection Control Program (2020 Infection Control Annual Plan and Risk Assessment) states:
1. Decrease the risk of infection to patients, visitors, and staff by facilitating targeted quality improvement work with frontline staff and supervisors/managers.
2. Limit unprotected staff and visitor exposure to pathogens on the inpatient units, procedural areas and clinics.