Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent to release information form from the client for the disclosure of information, in four of sixteen client records.
The findings include:
Sixteen client records were reviewed on October 24, 2011 for documentation of an informed and voluntary patient consent for the release of information. The facility did not obtain an informed and voluntary consent for the disclosure of client information in accordance with the regulations in client records, # 2, 3, 6, 11, 13 and 14.
Client record #2 contained a consent to release form,dated 10/11/11, that provided for the release of information to the client's family. The release of information form had a designated area to specify that the patient received his/her copy of the document; this area was left blank and one was unable to determine if the patient received their copy. Also the client signed and dated the consent to release form on 10/11/11; however, staff signed and dated the consent as a witness on 10/7/11.
Client record # 3 contained a copy of a fax that was sent on 10/13/11 regarding client # 3 that was addressed "To Whom It May Concern". It could not determine the recipient of the information and whether there was a consent to release form signed to disclose information.
Client record #11 contained documentation of a consent to release information, dated 10/12/11. This consent to release information form did not document the agency that would receive the information, the purpose for the release and what information was being released.
Client record #13 contained a consent to release information that included a stamped date on the consent to release information forms, dated 9/30/11, for agencies, an insurance company, family, pharmacy and lab.
This is a repeat citation.
The facility was previously cited for noncompliance of this standard during the March 15-17, 2011 licensing inspection.
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Plan of Correction
Standard 709.28 (c ) Confidentiality:
The Director of Clinical Services conducted a training for Clinical and Admissions staff on October 28, 2011. All releases of information will include the name of the agency receiving information as well as the name of the specific person if applicable. All releases of information will indicate the purpose for the release and will indicate what information will be released. All releases of information will indicate whether the client received a copy of the release or chose not to receive a copy. Staff will witness releases on the same date as the client signs the release. All releases will be dated manually in writing. Compliance will be monitored through monthly chart audits conducted by the Director of Clinical Services. Results will be presented in Monthly Performance Improvement meeting.
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