Observations
Based on a review of client records and staff interview, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record, which includes the name of the person, agency or organization to whom disclosure is made, in five of five records.
Client #1 was admitted to the outpatient level of care on October 8, 2025 and was active at the time of review. Client #1 ' s record had a release of information that facility staff confirmed to be for client #1 ' s funder, however the release of information did not indicate the name to whom information was to be disclosed to.
Client #2 was admitted to the outpatient level of care on December 3, 2025 and was active at the time of review. Client #2 ' s record had a release of information that facility staff confirmed to be for client #2 ' s funder, however the release of information did not indicate the name to whom information was to be disclosed to.
Client #3 was admitted to the outpatient level of care on December 29, 2025 and was discharged May 12, 2026. Client #3 ' s record had a release of information that facility staff confirmed to be for client #3 ' s funder, however the release of information did not indicate the name to whom information was to be disclosed to.
Client #4 was admitted to the outpatient level of care on March 18, 2026 and was discharged July 27, 2026. Client #4 ' s record had a release of information that facility staff confirmed to be for client #4 ' s funder, however the release of information did not indicate the name to whom information was to be disclosed to.
Client #5 was admitted to the outpatient level of care on May 7, 2026 and was discharged September 10, 2026. Client #5 ' s record had a release of information that facility staff confirmed to be for client #5 ' s funder, however the release of information did not indicate the name to whom information was to be disclosed to.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon receipt of the notice of deficiency, October 2, 2026, the Facility Director and the Clinical Supervisor met to develop a revised Release of Information that specifies the name of the person, agency, or organization to whom disclosure will be made. On the same day, the Clinical Supervisor entered the new form into the Electronic Medical Record.
On October 5, 2026, at our All Clinical Staff Meeting, the Clinical Supervisor explained the DDAP Licensing Visit deficiency to all clinical staff and outlined our plan to correct all client files.
Beginning on October 6, 2026, the Clinical Supervisor instructed the Assessment Coordinator to begin using the new Release of Information with all new admissions.
On the same date, the Clinical Supervisor instructed all clinical staff to begin updating releases of information in all client files with the new form. The updates are to occur at the clients next clinical appointment. Further, the Clinical Supervisor set a deadline of November 15, 2026 for all updates to be completed.
To ensure completion, Chart Reviews will be completed in weekly supervision meetings beginning on November 16, 2026.
Quarterly chart reviews will be assigned by the Clinical Supervisor and completed by the Facility Director, the Clinical Supervisor, and assigned substance abuse team members. The Reviews must be completed by the last day of the quarter. (December 31, March 30, June 30 and October 31)
If reviews are not completed by the last day of the quarter the responsible clinical staff will meet with their supervisor and receive a written performance improvement plan. Once the deficiency is corrected the correction will be recorded by the Clinical Supervisor and reported to the Facility Director.
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