Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for disclosure of emergency information, including the specific information to be disclosed and the purpose of disclosure in eleven of eleven client records.
The findings included:
Eleven client records requiring an informed and voluntary consent form from the client, including the specific information to be disclosed and the purpose of the disclosure, were reviewed on October 16, 2014. The facility failed to obtain an informed and voluntary consent from the client; including the specific information to be disclosed and the purpose of disclosure in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11.
All eleven client records had emergency consent forms signed by the respective clients that identified "911" as the organization the information would be disclosed to. All of the client consent forms had the specific information to be disclosed identified as "anything necessary to provide treatment" and the purpose of the disclosure was identified as "emergency situations." The information to be disclosed and the purpose identified on the consent forms was not specific enough to allow proper disclosure of information.
These findings were reviewed with facility staff via telephone on November 19, 2014.
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Plan of Correction
On November 19, 2014, a new emergency release was designed and was immediately put to use in all clinical charts. Beginning December 1, 2014 all charts will contain the new emergency release which is more specific than the previous version, and was designed to comply with all licensing requirements. The staff was trained by the clinical director on the use of the new form, and the quality assurance staff will monitor it's correct usage to remain in compliance with licensure regulations. |