Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consents in two of six records reviewed.
The findings include:
Six client records were reviewed on November 16, 2015. All were reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in three client records, specifically record, #1, 2 and 6.
Client #1 - Consent to release dated October 5, 2015 failed to document the name of the person, agency or organization to whom disclosure is made and the purpose of the disclosure.
Client #2 - Consent to release dated November 10, 2015 failed to document the name of the person, agency or organization to whom disclosure is made.
Client #6 - Consent to release dated October 22, 2015 failed to document the name of the person, agency or organization to whom disclosure is made and the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency will be corrected in current charts by client resigning new consents and old consents removed. Staff retrained on the procedure 11/27/2015. Consents redesigned to allow 5 points only and replaced in Master file for duplication as new clients arrive. The clinical supervisor will complete chart audits and review all releases and consents twice a month for then next 6 months then monthly there after. Director met with staff and explained the proper process for documenting releases. Additional random audits to be conducted monthly by the director. |