Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in one record reviewed.
Client #1 was admitted on May 11, 2021 and discharged on June 4, 2021. There was not an informed and voluntary consent from the client for the disclosure of information to their funder documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Response:
Crossroads Counseling, Inc. fully intends to comply with all requirements regarding confidentiality.
This is a new facility for us and unfortunately this consent form was missed at client intake. The intake worker thought the client was being funded by a different source (whom we did have consent for) and therefore neglected to obtain consent for the actual funder. The client only attended one appointment with our office and by the time we discovered the oversight, the client was already discharged. We fully recognize the need for complete and accurate records including the completion of a proper consent form for the funder. Effective 10/13/2021, all staff have been reminded of which consent forms are needed. Consent forms will be regularly reviewed in weekly clinical supervision as well as through random file audits. Director will follow up monthly with clinical supervisors to assure continued compliance.
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