Observations
Based on a review of client records and an interview with the project/facility director, the facility failed to obtain an informed and voluntary consent from the client which included the purpose of disclosure, specific information to be disclosed and the name of the person, agency or organization to whom disclosure is made in two of four client records.
The findings include:
Four client records were reviewed on February 4, 2010. Four client records were required to include documentation of an informed and voluntary consent from the client which includes the purpose of disclosure, specific information to be disclosed and the name of the person, agency or organization to whom disclosure is made in two of four client records; as required by regulation. Client records # 1 and 3 did not include documentation of an informed and voluntary consent to release client information.
Client # 1 was admitted on January 2, 2010 and discharged on January 5, 2010. On January 2, 2010, the client signed a release of information which did not include the purpose of disclosure, specific information to be disclosed or the name of the person, agency or organization to whom disclosure was being made. On January 2, 2010 the client signed a release of information which did not include the name of the person, agency or organization to whom disclosure was being made. The release of information listed the name of the agency as "aftercare". It did not actually list the name of the organization.
Client # 3 was admitted on December 31, 2009 and discharged on January 1, 2010. On December 31, 2009, the client signed a release of information form which did not include the purpose of disclosure, specific information to be disclosed or the name of the person, agency or organization to whom disclosure was being made. On December 31, 2009 the client signed a release of information which did not include the name of the person, agency or organization to whom disclosure was being made. The release of information listed the name of the agency as "aftercare". It did not actually list the name of the organization.
On February 4, 2010, at approximately 10:30 AM, the project/facility director was interviewed. The project/facility director confirmed that these releases of information did not include the required information. The project/facility director reported these releases were given to the clients by the technicians handling the intake process. The release of information that listed the name of the agency as "aftercare" is utilized if the client transfers to another program. The project/facility director reported that staff appeared to have completed the releases of information prior to knowing where the client would be attending an aftercare program.
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Plan of Correction
The facility will follow all requirements with regard to confidentiality and disclosure of client-oriented information.
The Facility Director or designee will conduct Unit Meetings wherein all staff on the Detox Unit will be re-trained in requirements and procedures surrounding completion of consents for release of information. This re-education will include ensuring the following at the time of review/signature of the client:
a. The entity to which information will be provided is specific and stated clearly.
b. The information to be released is clearly written.
c. The purpose for sharing information is clearly written.
The Facility Director or designee will perform chart audits to ensure these requirements are met.
Chart sudits will be performed for 1 quarter or until substantial compliance is met.
Chart audits will be forwarded to the PI/UR/MR Committee for review. |