Observations
Based on a review of client records, the facility failed to document a consent to release information form that included the specific information disclosed in two of eight records.Client # 1 was admitted July 26, 2018. A consent for a doctor dated January 25, 2022 indicated the information to be disclosed was the "general medical record". A consent for a hospital dated February 1, 2022 indicated the information to be disclosed was the "general medical record". No specific information disclosed was documented on these consents for client # 1.Client # 2 was admitted August 18, 2021. A consent for a doctor dated August 18, 2021 indicated the information to be disclosed was "general medical information". A consent for a doctor dated February 18, 2022 indicated the information to be disclosed was "full consent for treatment information". No specific information disclosed was documented on these consents for client # 2.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This Plan of Correction will be completed and implemented by Facility Director, Clinical Supervisor and Lead Counselor.
Facility Director emailed Pinnacle Quality Director to assist with ensuring the fill-in box on the electronic consents are able to be expanded to not limit the length of text needed for proper completion. This will be remedied by the 4/20/22 Clinical staff meeting.
A clinical staff meeting has been scheduled for 4/20 to discuss the proper way to indicate the information needed to be disclosed on consents. The statement of "general medical information" cannot be used, rather, the specific items that are to be released must be spelled out in detail on each consent. This will be discussed in individual supervision sessions (done monthly by Clinical Supervisor and Lead Counselor) and in the 4/20 staff meeting.
The Clinical Supervisor will be responsible to review consents completed to ensure this is implemented by all staff in completion of consents. |