Observations
The facility failed to document an informed and voluntary consent from the client prior to the release of information contained in the client record in two of twelve client records reviewed during the annual licensing inspection conducted on August 17 - 18, 2017.
A prior authorization for medication was faxed to the insurance company and included the name and diagnosis of the client.
Client # 1 was admitted on July 3, 2017. The disclosure occurred on July 13, 2017
Client # 6 was admitted on October 16, 2016 and discharged on April 18, 2017. The disclosure occurred on November 17, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/17/2017 the Clinical Supervisor met with the Administrative Assistant to develop and implement a change in FCDAC's process for obtaining the correct consents for the Department of Human Services in order to cover physical health plans. Any new client the clerical and or treatment staff will identify the appropriate physical health plan and obtain a release of information from the client. This release will be place into the clients chart in section #5. For existing clients the clerical and or treatment staff will obtain a consent for the physical health plan at the clients next appointment. In order to ensure compliance the Treatment supervisor will conduct random chart audits to verify appropriate releases have been obtained for the physical health plans. |