Observations
Based on five of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include the dated signature of the client. Informed and voluntary consent forms from the client were completed on behalf of the client from staff and only indicated a verbal consent from the client in client records # 1, 2, 3, 4, and 6.
Client # 1 was admitted on June 30, 2021 and was still active at the time of the inspection.
An informed and voluntary consent from the client for the disclosure of information to a funding source, PCP, Emergency contact, and other agency had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 2 was admitted on June 9, 2021 and was still active at the time of the inspection.
An informed and voluntary consent from the client for the disclosure of information to a funding source had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 3 was admitted on June 24, 2021 and was still active at the time of the inspection.
An informed and voluntary consent from the client for the disclosure of information to a funding source had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 4 was admitted on May 26, 2021 and was still active at the time of the inspection.
An informed and voluntary consent from the client for the disclosure of information to a funding source, PCP, Emergency contact, and other agency had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
Client # 6 was admitted on June 14, 2021 and was discharged on June 30, 2021.
An informed and voluntary consent from the client for the disclosure of information to a funding source had a dated signature of a witness however, it only contained a verbal telehealth consent by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Whereby telehealth is done the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to: (4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients). When verbal consent is given during a telehealth session the clinical staff person will follow up with a written consent prior to the release of confidential client information. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |
Observations
Based on one of one applicable client record reviewed, the facility failed to provide documentation of treatment and rehabilitation plans being reviewed and updated at least every 60 days in client record # 5.
Client # 5 was admitted on March 8, 2021 and discharged on June 3, 2021. A treatment and rehabilitation plan was developed on March 8, 2021. A treatment and rehabilitation plan update was due no later than May 8, 2021. There was no treatment and rehabilitation plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical staff will assure treatment and rehabilitation plans shall be reviewed and updated with the client at least every 60 days per Diakon Family Life Service's policy. This will be in compliance effective 8/2/2021. Compliance with this standard will be monitored and enforced by the Facility Director and Clinical Coordinator through staff meetings, staff training, quality review and supervision. |