Observations
Based on a review of applicable client records, the facility failed to document the specific information to be disclosed on signed consent forms in two of seven client records.
Client #1 was admitted on October 28, 2024 and was still active at the time of the inspection. An informed and voluntary consent was signed on October 28, 2024. This consent stated, " coordination of care. " This does not qualify as specific information.
Client #2 was admitted on September 25, 2024 and was still active at the time of the inspection. An informed and voluntary consent was signed on September 25, 2024. This consent stated, " coordination of care. " This does not qualify as specific information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program will review and maintain compliance with state regulation (709.28 (c) (2) regarding Confidentiality. The Treatment Center's Facility Director and Clinical Supervisor will implement training specific to this concern, and conduct an ongoing review of practices to ensure the correct and appropriate completion of all releases of information, specifically covering the information released and purpose of the release. This process will include the implementation of a revised ROI training imediately, as well as annual trainings pertaining to the completion of releases of information. In addition the clinical supervisor will review the content of all releases during the quality review process conducted monthly. All training will be administered by the Facility Director and/or Clinical Supervisor, and quality reviews will be completed during peer chart reviews by the Clinical Supervisor.
All clinical and COE staff members participated in the updated training on 3/6/25 to review the concerns presented during this audit and provide guidance on the correct completion of ROI's. |