Observations
Based on a review of client records, the facility failed to document whether or not the client was offered a copy of the consent to releases information forms in three of ten records reviewed.
The findings include:
Ten client records were reviewed on January 9, 2015. All were reviewed for informed and voluntary consent forms. The facility failed to document whether or not the client was offered a copy of the consent to releases in three client records, specifically record, #3, 4 and 7.
Client #3 - The facility failed to document whether or not the client was offered a copy of the consent to releases dated October 13, 2014 and October 16, 2014 for an agency.
Client #4 - The facility failed to document whether or not the client was offered a copy of the consent to release dated October 1, 2014 for the client's funding source.
Client #7 - The facility failed to document whether or not the client was offered a copy of the consent to release dated July 14, 2014 for a government agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will oversee that all staff are re-educated via staff meeting to complete all consents thoroughly, to include whether the client accepted/refused a copy. Office administration will ensure ongoing compliance by checking all releases for completion prior to scanning the documents into the electronic record. The Quality Improvement Department will also monitor for ongoing compliance via random chart audits. |