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Through Interview and record review the hospital failed (1) of (1) patient by not following its own HIPAA policy. The hospital failed a different patient's personal privacy by providing personal medical information over the telephone to Patient #1's legal guardian.

Findings include:

Through interview with Staff # 2 amd 3 the surveyor was informaed that a weekend staff provided the legal guardian of Patient #1 with another Patient's information by reading it out of the medical chart over the telephone.

Through interview and record review the hospital staff did not follow it's own policy. Staff # 2 and #3 both identified this to the surveyor. The hospital policy provided to the surveyor.

Policies:
The hospital Policy HIPAA Privacy Training dated 01/23/2018 reflected, "Facility workforce members are required to receive HIPAA training to help assure compliance with Facility HIPAA policies and procedures, as necessary and appropriate for them to carry out their functions. Initial and recurrent training will be provided to Facility employees for whom training is necessary and appropriate for them to carry out their functions. Initial training will be provided within 30 days after the person joins the workforce.
Workforce members will be trained on the Facility's HIPPA policies and procedures with request to PHI, as necessary and appropriate for them to carry out their functions within the facility. Initial training will be provided within a reasonable time after the person joins the workforce."

The hospital Policy to Patient Complaints and other Privacy-Related Complaints dated 001/23/20218, reflected, "An individual who believes that their privacy rights with respect to PHI have been violated has the right to complain to the Facility or to the Secretary of Health and Human Services (the 'secretary'). Facilities will provide a process for individuals to make complaints concerning violations of patient privacy rights and/or the Facility HIPAA privacy policies and procedures including breach notification issues, Facilities ill receive complaints from individual without threat of retaliation, and will cooperate with the Secretary, if the Secretary undertakes an investigation or compliance review of Facility policies, procedures, or practices."

Through record review and interview the hospital failed (1) of (1) patient Pateint #1 by failing to complete a post-discharge plan of care that was developed with the participation of the resident and his or her family, which will assist the resident to adjust to his or her new living environment. The hospital failed to comply with its own policy relating to discharge.

Findings Include;

Through record review of Patient #1's medical record the record did not reveal any form of documentation of Discharge.

Through interview Hospital Staff # 5, 3 and 2 all identified in review of the medical record with the surveyor, that the hospital failed to complete a discharge plan on the family. The staff were given the opportunity to review Patient #1's medical record and they all stated; "There is no documentation of a Discharge Summary reflected in the record."

Through Interview Staff # 2 reported that each medical record is supposed to have a completed discharge planning documention in the record and presented to the patient and or their legal guardian. Staff # 2 was in agreement with the surveyor that the hospital failed to follow its own policy.

Policy:
The hospital Policy DISCHARGE PROCESS dated 06/26/2019 reflected, "UBH = Denton, Texas is committed to providing a safe, timely and organized process for a patient's discharge/transfer from the hospital ...The case manager/therapist will complete the Discharge Risk Assessment on the day of discharge ...The case manager/therapist will complete the Discharge After Plan (CC0902) and review all discharge recommendations with the patient ...The case manager/therapist will review the patient's Crisis Safety Plan (#CC0704) and ensure the following;
a. All sections are completed/addressed (particular attention paid to the documentation of ensuring patient does not have access to weapons or other lethal means.)
b. Patient has signed the Crisis Safety Plan form
c. Parent/guardian signature if the patient is a minor
d. Therapist has signed the form
The RN will review the following to ensure it is completed, signed, dated and timed as indicated;
a. Physician Discharge Order
b. Discharge Aftercare Plan
c. Discharge Medication Reconciliation
d. Crisis Safety Plan Prescription/s
Signatures are required on the following
i. Discharge After care Plan (#CC0902)
ii. Discharge Medication Reconciliation Form (#CC0507)
iii. Patient Belongings Inventory (#CC0527)

The hospital Policy Request for Early Release/Discharge dated 05/22/2019, reflected, "It is the policy of University Behavioral Health - Denton, Texas to ensure that the rights of all patients admitted to the facility are respected. A voluntary patient over the age of 16 has the right to request discharge at any time after admission to UBH - Denton per the Texas Mental Health Code. Patients and legal guardians requesting discharge prior to physician's recommendations may be discharged Against Medical Advice (AMA)."