Observations
Nine client records were reviewed for the renewal inspection on February 9, 2017. The facility failed to document an informed and voluntary consent where consent was applicable in client record # 1. Client # 1 was admitted into treatment on 9/21/16 and was still active in treatment. Documentation in the client's record indicated that the facility faxed client-related information to an SCA agency, the client's treatment funding source, on 9/27/16. A consent to release information to the SCA agency was not documented in the client's record. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A consent to release to the SCA agency was completed for Client #1 on 2/22/2017. All administrative and clinical staff will be re-educated during staff meeting on 3/13/2017 to ensure that all necessary consents to release are obtained for each client. Office administration and the Quality Improvement Department will conduct chart audits to ensure ongoing compliance. |