Observations
Based on a review of client records and an interview with the Facility Director, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
The findings include:
Four client records were reviewed on November 9, 2010 for documentation of written consents from the client for the disclosure of information contained in the record.
The facility failed to obtain an informed and voluntary consent for the disclosure of client information to an outside facility in one of four client records reviewed, specifically, client record # 1.
Client # 1 was admitted to the program on April 28, 2010 and discharged on June 15, 2010.
The client was referred to an outside residential facility.
Verification of this referral was obtained by reviewing the client's progress notes, aftercare plan, discharge summary, and follow-up documentation.
The documentation indicated that the client was being discharged to an outside residential facility.
The facility transported the client to the residential facility; however, the facility did not document an informed and voluntary consent from the client for the disclosure of information.
An interview was conducted with the Facility Director on November 9, 2010.
The Facility Director reviewed client record # 1 and confirmed that record # 1 did not contain an informed and voluntary consent from the client for the release of information to the other treatment facility.
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Plan of Correction
The Facility Director will insure that all counselors and case managers obtain an informed and voluntary consent from the client for the disclosure of information contained in the client's record. The facility director will conduct periodic spot reviews of active cases for the sole purpose of checking the informed consent. Counselors and case managers will be reminded, via meetings, supervision and memo to make sure all consents are obtained properly |