Observations Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of disclosure in thirteen out of twenty-eight records reviewed.
Client #1 was admitted on March 10, 2025 and discharged on May 15, 2025. A release form to an emergency contact, dated March 4, 2025, had "other" checked for purpose without identifying an additional purpose.
Client #2 was admitted on March 17, 2025 and discharged on May 14, 2025. A release form to an emergency contact, dated February 11, 2025, had "other" checked for purpose without identifying an additional purpose.
Client #5 was admitted on April 10, 2025 and discharged on May 23, 2025. A release form to an emergency contact, dated March 7, 2025, had "other" checked for purpose without identifying an additional purpose.
Client #6 was admitted on March 24, 2025 and discharged on May 30, 2025. A release form to an emergency contact, dated February 27, 2025, had "other" checked for purpose without identifying an additional purpose.
Client #7 was admitted on March 18, 2025 and discharged on June 13, 2025. A release form to an emergency contact, dated March 18, 2025, had "other" checked for purpose without identifying an additional purpose.
Client #8 was admitted on May 14, 2025 and discharged on June 13, 2025. A release form to an emergency contact, dated April 10, 2025, had "other" checked for purpose without identifying an additional purpose.
Client #10 was admitted on May 27, 2025 and discharged on July 3, 2025. Five release forms to medical facilities, dated May 28, 2025, did not list a purpose.
Client #14 was admitted on June 30, 2025 and discharged on August 18, 2025. A release form to a housing organization, dated September 2, 2025, did not list a purpose.
Client #15 was admitted on March 23, 2025 and discharged on April 21, 2025. A release form to an emergency contact, dated March 17, 2025, had "other" checked for purpose without identifying an additional purpose.
Client #16 was admitted on March 27, 2025 and discharged on April 30, 2025. Two release forms to an emergency contact, dated March 27, and April 10, 2025, had "other" checked for purpose without identifying an additional purpose.
Client #17 was admitted on March 28, 2025 and discharged on May 1, 2025. A release form to an emergency contact, dated March 28, 2025, had "other" checked for purpose without identifying an additional purpose.
Client #22 was admitted on April 20, 2025 and discharged on April 24, 2025. A release form to an emergency contact, dated April 20, 2025, had "other" checked for purpose without identifying an additional purpose.
Client #23 was admitted on April 23, 2025 and discharged on April 25, 2025. A release form to an emergency contact, dated April 23, 2025, had "other" checked for purpose without identifying an additional purpose.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction All clinical and administrative staff were re-trained on the requirement to obtain and document a completed consent to release information form for each client at admission and prior to any release of information. Audits by the Compliance Coordinator will take place on a monthly basis.
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