Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which included the date, event or condition upon which the consent will expire in ten out of ten client records reviewed. In addition, the facility failed to identify the specific information to be disclosed and the purpose of disclosure in one of ten client records reviewed. The facility also failed to include the name of the person, agency or organization to whom written disclosure was made in one of ten client records reviewed.
The findings include:
Ten client records were reviewed on January 13 and 14, 2015. All ten client records were required to include an informed and voluntary consent from the client that included the date, event or condition upon which the consent would expire. An informed and voluntary consent that included the date, event or condition upon which the consent would expire was not obtained in client record #1, 2, 3, 4, 5, 6, 7, 8, 9. 10. An informed and voluntary consent which identified the specific information to be disclosed and the purpose of disclosure was not obtained in client record #8. The facility failed identity of the person, agency, or organization to whom written disclosure was made in client record #6.
Client #1 was admitted on December 11, 2014 and was still an active client at the time of the inspection. The facility failed to obtain an informed consent that included the date, event or condition upon which the consent would expire.
Client #2 was admitted on December 9, 2014 and was still an active client at the time of the inspection. The facility failed to obtain an informed consent that included the name and address of the person, agency or organization to whom disclosure was to be made as well as the date, event or condition upon which the consent would expire.
Client #3 was admitted on December 3, 2014 and was still an active client at the time of the inspection. The facility failed to obtain an informed consent that included the date, event or condition upon which the consent would expire.
Client #4 was admitted on July 29, 2014 and was discharged on August 21, 2014. The facility failed to obtain an informed consent that included the date, event or condition upon which the consent would expire.
Client #5 was admitted on September 12, 2014 and discharged on October 20, 2014. The facility failed to obtain an informed consent that included the name and address of the person, agency or organization to whom disclosure was to be made as well as the date, event or condition upon which the consent would expire.
Client #6 was admitted on July 30, 2014 and was still an active client at the time of the inspection. The facility failed to obtain an informed consent that included the date, event or condition upon which the consent would expire. In addition, the facility failed identity of the person, agency, or organization to whom written disclosure was made.
Client #7 was admitted on May 29, 2014 and discharged on December 12, 2014. The facility failed to obtain an informed consent that included the client's name and the date, event or condition upon which the consent would expire.
Client #8 was admitted on September 18, 2013 and was still an active client at the time of the inspection. The facility failed to obtain an informed consent that included the name and address of the person, agency or organization to whom disclosure was to be made as well as the date, event or condition upon which the consent would expire. In addition, the facility failed to identify the specific information to be disclosed and the purpose of disclosure.
Client #9 was admitted on September 17, 2013 and discharged on May 15, 2014. The facility failed to obtain an informed consent that included the client's name and the date, event or condition upon which the consent would expire.
Client #10 was admitted on September 28, 2012 and discharged on May 27, 2014. The facility failed to obtain an informed consent that included the client's name and the date, event or condition upon which the consent would expire.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
An in-service will be held on February 4, 2015 to address the issue. The Clinical Supervisory staff will be responsible for re-training the staff in the area relating to informed and voluntary consent forms. There will be a focus on the areas listed in the observation. The Executive Director will be responsible for continued oversight.
This area will receive intensive attention in the quarterly case file reviews and in the weekly Quality Assurance meetings. |