Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consent, in writing, which includes specific information to be disclosed in ten of ten client records.
Client #1 was admitted on August 16, 2023, and was still active at the time of the inspection. A release of information form signed for a friend/family member and dated August 18, 2023, did not indicate the specific information to be released.
Client #2 was admitted on September 5, 2023, and was still active at the time of the inspection. A release of information form signed for corrections and September 5, 2023, did not indicate the specific information to be released.
Client #3 was admitted on August 4, 2023, and discharged on September 5, 2023. A release of information form signed for an emergency contact and dated August 4, 2023, did not indicate the specific information to be released.
Client #4 was admitted on March 24, 2023, and discharged on June 23, 2023. A release of information form signed for probations and dated March 24, 2023, did not indicate the specific information to be released.
Client #5 was admitted on June 8, 2023, and discharged on September 21, 2023. A release of information form signed for an emergency contact and dated June 8, 2023, did not indicate the specific information to be released.
Client #6 was admitted on April 4, 2023, and discharged on August 29, 2023. A release of information form signed for corrections and dated April 4, 2023, did not indicate the specific information to be released.
Client #7 was admitted on March 31, 2023, and discharged on June 6, 2023. A release of information form signed for probation and dated March 31, 2023, did not indicate the specific information to be released.
Client #8 was admitted on March 10, 2023, and discharged on June 2, 2023. A release of information form signed for an emergency contact and dated March 10, 2023, did not indicate the specific information to be released.
Client #9 was admitted on June 30, 2023, and discharged on October 12, 2023. A release of information form signed for probation member and dated June 30, 2023, did not indicate the specific information to be released.
Client #10 was admitted on March 6, 2023, and discharged on August 28, 2023. A release of information form signed for corrections and dated March 6, 2023, did not indicate the specific information to be released.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Project Director shall amend informed and voluntary consent forms from the client for the disclosure of information contained in the client record. The amendment shall include consent in writing to include, but not be limited to specific information disclosed. This will be completed on or before 1/5/24 Project Director and/or Facility Director shall train counselors on the use of the amended form. This shall be completed on or before 1/5/24. Facility Director shall review two client records per counselor per month to ensure compliance. This shall commence after training, no later than 1/5/24 Active clients shall have the amended form reviewed and updated and recorded in the clinical records. Counselors shall begin correcting forms with active clients beginning no later than 1/5/24. |