Observations
Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosure.
Client #4 was admitted on December 13, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated December 10, 2022 to a funding source did not provide the purpose of the disclosure.
Client # 7was admitted on May 25, 2022 and was discharged on September 20, 2022. An informed and voluntary consent from the client for the disclosure of information dated May 25, 2022 to an outside agency did not provide the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Outpatient Services will be responsible for the overall oversight of audits as well as peer audits will occur to ensure adherence to a particular form to be completed that will track and initiate the Staff member completing the consents to do so correctly. This was addressed immediately after the date of the inspection with re-training of the entire department both in a group supervision as well as one on one. Facility to be in full compliance with the standard immediately. |