Observations
The facility failed to document a complete release of information form prior to the disclosure of information in three of seven records reviewed during the July 13 - 14, 2017 annual inspection.
Client #3 was admitted on 1-10-2017 and discharged on 6-6-2017. A release of information was signed on 2-15-2017, and did not include the purpose of disclosure.
Client #5 was admitted on 4-27-2017 and discharged on 5-17-2017. A release of information was signed on 4-27-2017, and did not include the purpose of disclosure.
Client #7 was admitted on 2-8-2017. A release of information to a government agency was signed on 2-22-2017, and the specific information to be disclosed exceeds the parameters of 255.5.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In order to become compliant with 709.28 confidentiality deficiency the Clinical Director assures that all staff will attend a refresher training on how to properly complete the consent to release information in an accurate and legal manner. The agenda for the refresher training will identify the importance of timely signatures and accurate dates on each document. Additionally, the purpose of the disclosure will be reviewed and the staff will be instructed to ensure that the specific information to be released does not exceed the parameters of 255.5. This plan of correction will be implemented immediately and began on 8/7/2017. |