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 four of ten client records.The findings include:Ten client records were reviewed on July 13-14, 2015. All ten client records were required to have documentation of an informed and voluntary consent from the client for the disclosure of information contained in the client record. Client records # 3, 5, 9 and 10 did not include documentation of a valid informed and voluntary consent.Client #3 was admitted on February 3, 2015 and discharged June 26, 2015. A release of information to the County Assistance Office was signed on February 3, 2015 and did not include a purpose for disclosure.Client #5 was admitted on April 16, 2015. An orientation checklist and a Client Expectations and Facility Guidelines form, both signed April 17, 2015, included the full name of another client who was the senior peer assigned.Client #9 was admitted on May 12, 2015. An orientation checklist and a Client Expectations and Facility Guidelines form, both signed May 12, 2015, included the full name of another client who was the senior peer assigned.Client #10 was admitted on April 21, 2015. An orientation checklist and a Client Expectations and Facility Guidelines form, both signed April 21, 2015, included the full name of another client who was the senior peer assigned.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/15/2015 the Assistant Director met with the clinical staff and reviewed all components of a valid consent form used by Davis Archway. Specific attention was given to the purpose of the release and ensuring that all documents are complete. The Assistant Director will ensure compliance with this policy by conducting periodic audits of client charts and release forms. This portion of the plan of correction was completed on 7/15/2015.
The remainder of the plan of correction will be addressed at our monthly staff meeting to be held on 8/6/2015. The Assistant Director had directed the change of the form to exclude the client signatures that would violate confidentiality. Going forward the policy will be having the administrative assistant write the first name and last initial of the senior peer on the sheet. All staff will be informed of this policy and it shall be completed by 8/6/2015. |