Observations
Based on a review of client records, the facility failed to document that copies of client consents were offered to the client in five of nine client records.
The findings include:
Client records were reviewed on October 27 - 28, 2011. Nine client records required that copies of client consents were offered to the client. The consent to release client information form has the following statement: "Consumer has been offered a copy of this release." Next to the statement there are two check off boxes that indicate whether the copy was accepted or refused by the client. The facility failed to document that copies of client consents were offered to the client in client records # 2, 4, 6, 7 and 13.
Client # 2 was admitted into treatment on August 30, 2011. A consent to release information to the funding entity, dated August 30, 2011, did not indicate whether the client had accepted or refused a copy of the consent.
Client # 4 was admitted into treatment on September 14, 2011. A consent to release information to the funding entity, dated September 14, 2011, did not indicate whether the client had accepted or refused a copy of the consent.
Client # 6 was admitted into treatment on April 18, 2011. Consents to release information to case management services and hospital services, dated April 18, 2011, did not indicate whether the client had accepted or refused a copy of the consent. Consents to release information to the criminal justice system, dated April 18 and July 13, 2011, did not indicate whether the client had accepted or refused a copy of the consent. Consents to the funding entity, dated April 18 and July 14, 2011 did not indicate whether the client had accepted or refused a copy of the consent.
Client # 7 was admitted into treatment on April 13, 2011. A consent to release information to the criminal justice system, dated April 28, 2011, did not indicate whether the client had accepted or refused a copy of the consent. A consent to release information to the funding entity, dated April 13, 2011, did not indicate whether the client had accepted or refused a copy of the consent.
Client # 13 was admitted into treatment on February 4, 2011. A consent to release information to case management services, dated February 4, 2011, did not indicate whether the client had accepted or refused a copy of the consent.
The facility director was interviewed throughout the licensing process and confirmed the findings.
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Plan of Correction
Facility Director will review Mercy Behavioral Health Policy and Procedure with project staff in staff meetings, the first being on 11/14/11, and throughout the project year, as well as individually in supervision, to make sure project staff are completing Release of Information forms properly and complying with documenting that clients were offered copies of informed signed consent to Release Information. |