Observations
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in seven of seven client records reviewed on August 27, 2018.
There was no documentation that the client was informed that the project, facility or clinical director may temporarily remove portions of the records prior to inspection by the client if the director determines the information may be detrimental and reasons for removing sections shall be documented in the record in client records # 1, 2, 3, 4, 5, 6 and 7.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Assistant Director will update the consumer consent to treatment form to include all 6 of the Client Rights listed in the DDAP Regulation § 709.30 by 11/01/2018.
All Center staff performing intake functions will be trained by the Outpatient Assistant Director on the new form, the review with consumers and the documentation requirements surrounding the updated rights information in the Electronic Health Record by 10/25/2018.
Beginning 11/01/2018 the new consent will be reviewed with each consumer at intake to treatment.
Beginning 11/01/2018 the consumer will be asked to sign that the rights have been reviewed with them during the consent process and documentation will reflect that copy of the document is offered to the consumer for their records.
All existing consumers will have a new consent completed to include a review of all required client rights by 1/1/2019.
The Intake Director or designee will monitor the implementation of this POC through monthly record reviews beginning 12/01/2018. |