Observations
Based on a review of client records, the facility failed to document a written consent to release information form that included the specific information disclosed in four of seven client records.Consents for the following records were documented during the intake process and did not include the specific information disclosed.Client # 4 was admitted December 2, 2021 and discharged December 26, 2021. A consent for probation did not indicate what information would be released. A consent for an emergency contact indicated "emergency contact" would be released. A consent for a government agency indicated "relevant information necessary to obtain public assistance" would be released.Client # 5 was admitted May 19, 2021 and discharged August 16, 2021. A consent for a government agency indicated "relevant information necessary to obtain public assistance" would be released.Client # 6 was admitted May 25, 2021 and discharged November 19, 2021. A consent for an emergency contact indicated "emergency contact" would be released. A consent for a government agency indicated "relevant information necessary to obtain public assistance" would be released.Client # 7 was admitted October 4, 2021 and discharged November 29, 2021. A consent for an emergency contact indicated "emergency contact " would be released. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Prior to the completion of the inspection, on 2/10/22, immediately following the discussion with the inspector pertaining to the consent forms, to remain in compliance with § 709.28 Confidentiality (c) the program director updated all consent forms to specifically state what information would be disclosed regarding the client. The consent for the emergency contact now includes the option for the selected person to be only an emergency contact and the client may choose only to communicate the nature of the emergency and location of the client. The consent for the Dept. of Public Assistance will only disclose whether or not the client is in treatment if they need this service. The consent form for the probation officer will include whether or not the client is in treatment, the prognosis of the client, the nature of the project, a brief description of the progress of the client, and a short statement of whether the client has relapsed into drug and alcohol abuse and the frequency of such a relapse. If a client chooses to disregard any of those options, the consent can be updated at their request. The project director will ensure that all staff receive the updated consents and disregard the prior consents that were being used. The program director will conduct random chart audits to ensure the correct forms are utilized that include the specific information disclosed. |