Observations
Based on a review of patient records, the facility failed to obtain a written, informed and voluntary consent from the patient prior to the disclosure of information contained in the patient record in two of seven patient records.
The findings include:
Seven patient records were reviewed for written, informed and voluntary consents on July 21, 2015. The facility failed to obtain a written, informed and voluntary consent from the patient prior to disclosing information contained in client records # 5 and 6.
Patient # 5 was admitted into treatment on June 2, 2015 and discharged on June 4, 2015. Information contained in the patient record was faxed to an insurance company for prescription authorization on June 3, 2015. The facility failed to obtain a written, informed and voluntary consent from patient # 5, prior to disclosing information to the insurance company.
Patient # 6 was admitted into treatment on May 10, 2015 and discharged on May 12, 2015. Information contained in the patient record was faxed to an insurance company for prescription authorization on May 11, 2015. The facility failed to obtain a written, informed and voluntary consent from patient # 6, prior to disclosing information to the insurance company.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clients that come in with managed care insurance will sign consent for both the physical health and the behavioral health provider.
Responsible Staff:
Admissions staff will obtain information on both providers prior to the admission of the client to Cove Forge.
Both consents will be added to the list of consents to be obtained by the detox techs on the admission of the client to Cove Forge.
The Director of Admissions will be responsible for educating the admissions staff by 09-01-15.
The Director of Nursing will be responsible for educating the Detox Technicians about obtaining the consents by 9-01-15.
100% of all opiate charts with managed care will be audited for 3 months for compliance. Auditing will be completed by Detox medical secretary.
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