Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of fourteen records reviewed.
Client #1 was admitted and discharged into the intake, evaluation and referral level of care on July 25, 2025. The client record contained a blank informed and voluntary consent form that was signed by the client on July 25, 2025, that did not contain any other information.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The finding was discussed with intake, evaluation, and referral staff. Policies regarding proper completion of informed and voluntary consent forms were reviewed, as well as procedures related to the contents of client records. Program staff will ensure consent forms in client records are completed thoroughly and in compliance with regulation 709.28(c).
Compliance will be monitored via internal audits conducted at least monthly by program leadership. |