Observations
Based on one of five client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.Client # 1 was admitted on February 9, 2021 and discharged on October 25, 2021. There was no documentation of an informed and voluntary consent to release information to an outpatient treatment provider this client was referred to for aftercare.This finding was reviewed with facility staff during the complaint investigation.
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Plan of Correction
The My Sister's Place-Thomas Jefferson University Program will obtain signed informed and voluntary consent to release specific information to any and all individuals, inpatient/outpatient providers and/or outside entities upon request by the client.
In order to prevent a reoccurrence of this information being unavailable in the client record for review, our Clinical Team members(which is comprised of the Clinical Director, Clinical Supervisor, Patient Care Manager, Patient Navigator and Counselor)will obtain an informed and voluntary consent to release information to an outpatient treatment provider from the client once the discharge planning/transfer process begins.
Since the My Sister's Place-Thomas Jefferson University program has moved to an electronic health record system, the Clinic Team members will follow the process listed below:
- Clinical Team members will have client electronically sign informed and voluntary consent to release information to the identified Outpatient Provider.
-Clinical Team members will then scan upload and attach all documents necessary to complete an outpatient transfer, including the consent form, into the client's electronic health record.
-Clinical Team members will then rename the upload "Transfer Packet" and attach it to the "Discharge" section of the client's electronic health record.
This plan of correction will be implemented effective 1/5/2022.
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