Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the specific information disclosed in two out of seven records reviewed.
Client #2 was admitted on May 2, 2025 and discharged on September 25, 2025. An informed and voluntary consent signed and dated by the client on June 2, 2025, for a physician ' s office, did not document the specific information to be disclosed.
Client #7 was admitted on September 18, 2024 and was current at the time of the licensing inspection. An informed and voluntary consent signed and dated by the client on September 18, 2024, for a physician ' s office, did not document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
All staff will be trained by the project and facility director on the appropriate and necessary way to complete consents and to ensure all are filled out properly. This will be monitored by directors on an ongoing basis. |