Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in four out of four records reviewed. Client #1 was admitted on March 5, 2024 and was still active at the time of the inspection. At the time of the inspection, no release of information was signed for the client's parent. Facility staff confirmed the client's parent was involved in the client's treatment. Client #2 was admitted on November 23, 2023 and was discharged February 14, 2024. At the time of the inspection, no release of information was signed for the client's parent. Facility staff confirmed the client's parent was involved in the client's treatment. Client #3 was admitted on September 25, 2023 and was discharge November 15, 2023. There was no release for the funding source; however, facility staff confirmed that billing had occurred. Client #4 was admitted July 8, 2023 and was discharged on October 20, 2023. There was no release for the funding source; however, facility staff confirmed that billing had occurred. These findings were reviewed with facility staff during the licensing inspection.This is a repeat citation from the May 23, 2023 licensing inspection .
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Plan of Correction
The Senior Compliance Manager and Director of Health Information met on 5/2/24 to discuss the findings during the inspection.
The Senior Compliance Manager and Director of Health Information determined that the process for obtaining the funding source release of information needed to be improved.
The current process was to request the funding source release at the time of admission. However, there was no follow-up if the client did not sign the initial request. The updated process is that the funding source release is re-sent for signature every week until the signature is obtained. In addition, if the client does not sign after the second follow-up, the Health Information team will notify the primary therapist and the primary therapist will ask the client/parent or guardian to sign the consent before their next scheduled session.
The Health Information team was trained on the updated process on May 10th, 2024.
The Senior Compliance Manager and Health Information Director provided a re-training to the primary therapist on the requirement to obtain a release of information for family members that are participating in the client's care, and/or family therapy.
The primary therapists were instructed to confirm that a release is signed and on file for a family member before initiating family therapy sessions.
The primary therapists were re-trained on May 14th, 2024.
The POC was fully implemented on May 14th, 2024.
The lead clinical quality analyst will monitor compliance with this plan of correction monthly.
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