Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of fourteen client records reviewed.
Client #7 was admitted to the outpatient activity on June 8, 2022 and was discharged on February 1, 2023. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On March 20, 2023 the Executive Director requested our Clinical treatment leader to update our QI form to include checking for releases when we are doing concurrent and DC reviews. Executive Director reviewed and approved and on March 21st gave to the rest of the staff at treatment team.
As an additional measure, Exeuctuive Director met with our clinical staff on March 21st requesting all of them to check each of their active client's releases, to assure they are present and up to date. We also requested that if they are done in a paper copy, that this will be additionally notated in the system so it is easy to check for QI purposes. Rather than the client signature in chart- it will state "Hard Copy on File" |