Observations
Based on a review of client intake documentation, the facility failed to document a consent to treatment for each client upon being admitted into the program.
The findings include:
Seven client records were reviewed for consent to treatment documentation on August 1, 2013. The facility failed to document consent to treatment forms in seven out of seven client records, specifically #'s 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on April 22, 2013. As of the date of inspection there was no verification that client # 1 had signed a consent to treatment.
Client # 2 was admitted on April 25, 2013. As of the date of inspection there was no verification that client # 2 had signed a consent to treatment.
Client # 3 was admitted on June 11, 2013. As of the date of inspection there was no verification that client # 3 had signed a consent to treatment.
Client # 4 was admitted on May 8, 2013. As of the date of inspection there was no verification that client # 4 had signed a consent to treatment.
Client # 5 was admitted on April 22, 2013. As of the date of inspection there was no verification that client # 5 had signed a consent to treatment.
Client # 6 was admitted on January 4, 2013. As of the date of inspection there was no verification that client # 6 had signed a consent to treatment.
Client # 7 was admitted on March 28, 2013. As of the date of inspection there was no verification that client # 7 had signed a consent to treatment.
The findings were discussed with the facility director prior to the exit interview.
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Plan of Correction
The Outpatient Addictions Services will begin using the Hospital Consent Form as of Sept 9, 2013. The Nurse Manager will educate the outpatient staff on the use of the form at the staff meeting on September 5, 2013.
Client #1 , #2 and #4 will sign the Hospital Consent Form by Sept 9th, 2013 or at their next scheduled visit.
Client #3 has been discharged from the program, however he did have a Hospital Consent in file from his inpatient treatment.
Client #5, #6 and #7 were records of discharged clients and they are not currently in the program.
The Manager will use the hospital Inpatient/Outpatient consent form as of September 9, 2013 following staff education and training.
The Clinical Supervisor will be responsible for performing audits of new client records beginning October 1, 2013 for 100% compliance that all clients are signing a Consent to Treatment form. This audit will be conducted for 3 months to demonstrate compliance then quaterly to demonstrate sustained compliance. The manager will present this plan and the audit results at the Behavioral Health Clinical Effectiveness and Quality Improvement (CEQI) meetings and to staff at staff meetings.
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