Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in two of ten records reviewed.The findings include:Ten patient records were reviewed on March 11, 2015. All were reviewed for informed and voluntary consent forms. The facility failed to document the counselor and patient signatures and/or dates on the informed and voluntary consents in two patient records, specifically record, #7 and 8.Client #7 - The facility failed to document the counselor's and patient's signature or date on the consent to release form for the patient's case worker. Client #8 - Consent to release form dated January 14, 2015 for the pharmacy didn't have the staff or patient signatures on the consent form.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility counselors voided all inappropriate consent forms from the client charts on 3/18/15. Client chart #7 and #8 now have all appropriate signed consent to release information forms.
The Facility Director will retrain facility staff on the appropriate completion of the informed and voluntary consent of information forms during clinical meeting on March 18, 2015.
The facility counselors will monitor appropriate completion via weekly client chart reviews beginning 3/20/15.
The Lead Counselor will monitor ongoing compliance through regular monthly client chart audits beginning 3/31/15.
|