Observations
The facility failed to obtain an informed and voluntary consent from a client for the disclosure of information in one out of one applicable charts reviewed during a complaint investigation conducted on 6/21/2023.
Client #1 was admitted to the facility on 2/13/2023 and was discharged on 3/3/2023. Chart documentation showed that the client was referred to a local sober living facility for aftercare. However, there was not a signed consent in the chart for the facility's referral to the sober living facility.
This was discussed with facility staff during the investigation.
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Plan of Correction
The Director of Q&PI reviewed the records; she also interviewed the case manager and the primary counselor 06/29/23. Both of the staff interviewed reported that facility staff did not make a referral and/or share information with the sober living facility. Although the patient was linked to the sober living facility, this occurred through direct contact between the patient and the sober living facility (when they were onsite to conduct a regularly scheduled AA meeting). On 2/22, the primary counselor had recommended the sober living facility to the patient's family, but they had not yet decided at that point. No consent was signed as our facility staff had not been directly involved in this referral. Also, the sober living facility does not request records from our facility.
Nonetheless, the Director of Q&PI recommended that, even if our facility is not directly involved, staff should document in more detail, going forward, how a referral occurred to the extent that the staff are aware of the referral. In addition, consents will be obtained even when facility staff are not directly involved with a referral to the extent that staff are aware of the referral. These action steps have been communicated to staff and are effective 7/11/23. |