Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in seven out of seven records reviewed.Client #1 was admitted on January 25, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #2 was admitted on February 6, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #3 was admitted on February 29, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #4 was admitted on September 7, 2023 and discharged on October 26, 2023. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #5 was admitted on August 10, 2023 and discharged on November 11, 2023. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #6 was admitted on September 19, 2023 and discharged on December 7, 2023. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #7 was admitted on January 9, 2024 and discharged on March 14, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director reviewed the requirement to obtain a consent to release information prior to releasing information with all clinical staff on 6/19/2024. SUD clinical director reviewed with medical staff that a release of information must be obtained prior to completing a medical prior authorization. SUD Clinical Director is requiring staff to complete all consents by 8/1/2024. SUD Director will complete chart audits to ensure all client charts are updated by 8/5/2024. Director will complete quarterly chart audits to ensure this deficiency does not happen again. |