Observations
The facility failed to obtain an informed and voluntary consent in three of seven patient records reviewed during the annual licensing inspection on September 13 - 14, 2017.Patient record #5 included documentation that information was disclosed without a valid release of information.Patient record #6 - A release of information was signed by the client on 8-22-2017, and did not include specific information to be disclosed.Patient record #7 - A release of information was signed by the client on 7-18-2017, and the specific information to be disclosed exceeds what is permitted in 255.5.These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to obtain an informed and voluntary consent in three of seven patient records.
Facility will discuss with PTC QA department changes on SMART releases that could possibly be made and add additional Release Templates within the SMART system.
A review of how to appropriately complete informed and voluntary consents will be conducted in staff meeting by Facility Director & Clinical Supervisor. Also PTC QA department will be conducting a Records Release training will all staff by the end of the 4th quarter 2017.
Facility Director, Clinical Supervisor, & Lead Counselor will continue to conduct regular record reviews to ensure accuracy and completeness of records. Supervisory staff will also review all outgoing correspondence to make sure correct releases are completed and appropriate information is being sent.
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