Observations
Based on a review of patient records, the facility failed to obtain an informed and voluntary consent from the patient prior to the disclosure of information in four of four patient records.
The findings include:
Four patient records were reviewed on December 3, 2014. Four patient records were required to include documentation of an informed and voluntary consent from the patient. All four records failed to include documentation of an informed and voluntary consent to release patient information to the funding source.
Client #1 was admitted to detoxification treatment on October 16, 2014 and was discharged on October 20, 2014. A release of information was not signed for the funding source.
Client #2 was admitted to detoxification treatment on August 25, 2014 and was discharged on August 30, 2014. A release of information was not signed for the funding source.
Client #3 was admitted to detoxification treatment on August 12, 2014 and was discharged on August 16, 2014. A release of information was not signed for the funding source.
Client #4 was admitted to detoxification treatment on October 18, 2014 and was discharged on October 20, 2014. A release of information was not signed for the funding source.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A new Release of Information has been created and will go to the MCH forms committee on 1/8/15 for approval. The form is specific for release of information to judges, probation or parole officers, insurance companies, health or hospital plans or government officials. The form includes the following to be released: whether the client is or is not in treatment, client's progress, name of the program, a brief description of the client's progress and short statement concerning relapse and frequency of relapse.
The new ROI will be instituted for all appropriate clients in the Detox Unit upon admission.
The form will be forwarded for approval to the MR/PI/UR Committee on January 20, 2015 and to the Medical Executive Committee on February 17, 2015.
Staff in the Detox Unit will be in-serviced on the new ROI by Nursing Administration by February 17, 2015.
Random audits will be performed of Detox charts by Nursing Administration over the next 3 months to monitor for compliance.
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