Observations
Based on a review of client records conducted during the onsite inspection, the facility failed to ensure the signed informed consent to release information forms had the required information documented in 3 of 7 records reviewed.
Client #1 was admitted for treatment on 03/01/2017, and was an active client at the time of the onsite inspection. The client had a signed consent to release information form dated 4/06/2017, for an individual, but the release of information lists, "verbal communication" as the information to be released. Verbal communication does not specify the information to be released.
Client #3 was admitted for treatment on 04/06/2017, and was an active client at the time of the onsite inspection. The client had a signed consent to release information form dated 4/07/2017, for an individual, but the release of information lists, "verbal communication" as the information to be released. Verbal communication does not specify the information to be released.
Client #5 was admitted for treatment on 08/23/2016, and was discharged on 01/30//2017. Client #5 had a signed cosnent to release information form dated 08/24/2016, for an individual, but the form did not list the purpose of the release.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Release of Information form used by the facility has been revised to clarify what type of information may be disclosed under the category "Verbal Communication."
The Release of Information form for residents #1 and #3, dated 4/6/2017 and
4/7/2017 respectively, have been resigned by the active residents. These consents now indicate what type of information can be released under the category "Verbal Communication."
The Release of Information form for resident #5, dated 8/24/2016, cannot be re-signed as this is a discharged resident.
In order to ensure future compliance, all Release of Information forms completed at admission will be audited for the following required elements:
1) Purpose of release.
2) If verbal communication is selected, notation of the type of verbal communication to be released.
Beginning 8/7/2017, monthly auditing will be completed by the Director of MIS, Quality & Regulatory Compliance for the first six months and then quarterly thereafter. |