Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated client signature in one of the seven client records reviewed.
Client #1 was admitted on December 1, 2020 and was still an active client at the time of the inspection. A release of information form for a government agency, signed and dated by a witness on January 14, 2021, did not have a client signature on it.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
On May 21, 2021 a clinical staff meting took place and the results of our annual DDAP inspection were reviewed. All staff were remined of the requirement to obtain a live signature from all patients for any release of information. Given the concerns with COVID, all staff were reminded that no patient information may be released until after a patient has signed a release of information. This topic will continue to be monitored and reviewed in all bi-weekly clinical staff meetings. Both the clinical supervisor and project director will continue to review charts to ensure compliance. |