Observations
The facility failed to document written acknowledgement that the clients were notified that: No client may be deprived of a civil rights solely by reason of treatment; Reasons for removing sections of the client's record shall be documented in the record and that the client has the right to appeal a decision limiting access to their records to the director, in eight of eight records reviewed on March 27-28, 2017.
Nine records were reviewed. Eight records were reviewed for documentation of client rights. Client records # 1, 2, 3, 4, 5, 6, 7 and 8 did not document that the client was informed of the above rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Changes were made to the Patient Rights section of the agency handbook to reflect this deficiency. A statement will be added stating: No client may be deprived of civil rights solely by reason of treatment. The following statements will be added to the section addressing clients' access to their records: Reasons for removing sections of your record will be documented in your record, and you have the right to appeal a decision limiting your access to your record to the program director.
Patient rights will continue to be reviewed at the intake appointment. An additional section will be added to the acknowledgement page of the intake document requiring the client's initials that the client rights have been reviewed.
These changes will be implemented by the clinical supervisor and reviewed with staff by the clinical supervisor to be completed by April 17th, 2017. The clinical supervisor will provide ongoing chart monitors to ensure that these changes are occurring.
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