Observations
Based on a review of the client records, the facility failed to document consent to release information forms that identified the specific information to be disclosed in eight of eight client records.
The findings include:
Eight client records were reviewed on January 30, 2013. The consent forms to release information in records # 1, 2, 3, 4, 5, 6,7,and 8 revealed that all consent to release forms failed to identify the purpose of the release.
Client # 1 was admitted on September 27, 2012. Release of information forms were signed on September 27, 2012. The facility failed to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client # 2 was admitted on August 22, 2012. A release of information form were signed on August 22, 2012. The facility failed to to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client # 3 was admitted on April 29, 2012. Release of information forms were signed on April 29, 2012. The facility failed to identify to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client #4 was admitted on September 25, 2012 and the last counseling session were documented as September 25, 2012. Release of information forms was signed on September 25, 2012. The facility failed to to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client #5 was admitted on June 29,2012 and discharged on June 29, 2012. Release of information forms were signed on June 29, 2012. The facility failed to identify to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client # 6 was admitted on April 23, 2012 and discharged on April 23, 2012. Release of information were signed on April 23, 2012. The facility failed to identify to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client #7 was admitted on November 10, 2011 and discharged on November 28, 2012. Release of information forms were signed on November 10, 2012. The facility failed to identify to identify the information to be released and the purpose of the release on all consent forms signed by the client.
Client #8 was admitted on June 17, 2011 and discharged on June 01, 2012. Release of information forms were signed on June 17, 2011. The facility failed to identify to identify the information to be released and the purpose of the release on all consent forms signed by the client.
This was confirmed by the Project/Facility Director on January 29, 2013.
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Plan of Correction
The Facility Director and the Clinical Director met with the treatment team on 1/30/13 and reviewed the findings of the DOH inspector. We reviewed the findings and discussed possible solutions and the implications of the releases of informaton not documenting the purpose of the release.
All files were pulled from the year 2011 through the current year and reviwed by the Clinical Director on 2/4/13 for further deficiencies and corrected by having the clinician meet with the client and reviewing if necessary.
A agency wide training (including all employees) will be conducted by the Facility Director on 3/14/13; the purpose will be to go over confidentiality, the scope of confidentiality, and how to identify the purpose for release, the 5 points of information that can be released, and how to properly fill out a release of information.
The agency was advised to remove the "other" denotation on the release of information. The Clinical Director removed all "other" denotations on the releases of information from the master copies and all previous copies have been shredded on 2/4/13 |