Observations
A review of eight client records was conducted on October 25, 2016. Based on this review, the facility failed to obtain an informed and voluntary consent from the client that included the name of the person, agency or organization to whom disclosure is made.
Client #2 was admitted on August 5, 2016 and still an active client as of the date of this inspection. The informed and voluntary consent that was signed by the client on August 5, 2016 did not contain the information to whom the consent would be disclosed.
Client #3 was admitted on August 24, 2016 and still an active client as of the date of this inspection. The informed and voluntary consent that was signed by the client on August 24, 2016 did not contain the information to whom the consent would be disclosed.
Client #5 was admitted on October 19, 2016 and still an active client as of the date of this inspection. The informed and voluntary consent that was signed by the client on October 19, 2016 did not contain the information to whom the consent would be disclosed.
These findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
Informed and voluntary consents were in client files but did not contain the information to whom the consent would be disclosed.
To correct this action an in house training took place on 10/31/2016 with the Intake Coordinator and the Executive Director to make sure sure that all informed and voluntary consents are filled out completely including to whom the consent will be disclosed to, dates, names and signatures.
All corrections were made on 10/31/2016.
To prevent re-occurrence of this deficiency the Executive Director and Intake Coordinator/Quality Assurance Coordinator will review client charts monthly, making sure all informed and voluntary consents are completely filled out including to whom the consent will be disclosed. |