Observations
Based on the review of client records, the facility failed to ensure that a completed informed and voluntary consent to release information form was obtained in seven of ten client records reviewed. Additionally, the facility failed to ensure that an informed and voluntary consent to release information form included the specific information to be disclosed in one of ten client records reviewed.
The findings included:
Ten client records requiring complete informed and voluntary consent to release information forms were reviewed on June 11, 2015. The facility failed to ensure that an informed and voluntary consent to release information form was completed in client records #1, 2, 3, 4, 5, 6, and 7. Additionally, the facility failed to ensure that the informed and voluntary consent to release information form included the specific information to be disclosed in client record #3.
Client #1 was admitted into treatment on April 17, 2014 and was discharged on September 2, 2014. There were authorization communications with the funding source on 4/17/14, 5/28/14, 6/27/14, 7/17/14, 8/15/14, and 9/2/14; however, there was no informed and voluntary consent to release information form documented in the client's record prior to the disclosure of information.
Client #2 was admitted into treatment on October 7, 2014 and was discharged on April 9, 2015. There were authorization communications with the funding source on 10/7/14, 10/21/14, 11/11/14, 12/2/14, 12/23/14, 1/13/15, 1/29/15, 2/12/15, 2/19/15, 2/26/15, 3/19/15, 3/31/15, and 4/9/15; however, there was no informed and voluntary consent to release information form documented in the client's record prior to the disclosure of information.
Client #3 was admitted into treatment on September 22, 2014 and was discharged on February 23, 2015. There were authorization communications with the funding source on 9/22/14, 10/7/14, 11/4/14, 12/5/14, 12/19/14, 1/21/15, and 2/3/15; however, there was no informed and voluntary consent to release information form documented in the client's record prior to the disclosure of information. Additionally, there was a consent to release information form to a hospital and a consent to release information form to a doctor's office, both dated 9/23/14, that did not document the specific information to be disclosed.
Client #4 was admitted into treatment on October 24, 2014 and was discharged on December 30, 2014. There were authorization communications with the funding source on 10/24/14, 11/8/14, and 12/18/14; however, there was no informed and voluntary consent to release information form documented in the client's record prior to the disclosure of information.
Client #5 was admitted into treatment on November 13, 2014 and was discharged on May 13, 2015. There were authorization communications with the funding source on 11/13/14, 12/2/14, 12/11/14, 12/15/14, 1/15/15, 2/19/15, 3/18/15, 4/14/15, and 5/7/15; however, there was no informed and voluntary consent to release information form documented in the client's record prior to the disclosure of information.
Client #6 was admitted into treatment on May 28, 2014 and was discharged on November 28, 2014. There were authorization communications with the funding source on 5/28/14, 5/30/14, 6/17/14, 7/17/14, 8/15/14, 9/12/14, 10/9/14, and 11/28/14; however, there was no informed and voluntary consent to release information form documented in the client's record prior to the disclosure of information. Additionally, there were telephone communications and inter-agency team meetings with the probation officer on 7/3/14, 7/10/14, 7/17/14, 7/25/14, 8/13/14, 8/21/14, 9/10/14, 9/18/14, 11/12/14, 11/18/14, and 11/25/14; however, there was no informed and voluntary consent to release information form documented in the client's record prior to the disclosure of information.
Client #7 was admitted into treatment on January 15, 2015 and was still an active client at the time of the inspection. There were authorization communications with the funding source on 1/15/15, 1/29/15, 2/27/15, 3/30/15, 4/28/15, and 5/29/15; however, there was no informed and voluntary consent to release information form documented in the client's record prior to the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ADL's/staff persons completing the consent forms will be re-trained on how to completed the consent form to release information and what is to be disclosed to the member's funding source and all hospitals, PO's, Doctors and entity we are releasing any information to by the assistant program director by 8//29/2015. Therapist will check the charts to assure that the consent to release to funders is completed and then placed in client's chart. The training will address specific's of what to be disclosed, what is to be released is checked on each consent. Client #1-#2-
#3- #4- #5 -#6 are no longer in treatment so consent form can not be signed by the client.
#7 Consent has been signed to release information and the specific's of what is to be disclosed and released is completed in it's entirety.
#3 The training will also address doctor's office and hospital visits to assure that the information to release and what is disclosed is specific on the consent for the doctor and the hospital. #3 is no longer in treatment so consent forms can not be signed by the client.
# 6 The training will also cover interagency team meetings to assure that every person in the meeting and every one who is talked to the phone regarding the member there will be a consent form signed that will be specific to what is to be released and what is to be disclosed.
The program Director will assure that all of the ADL's/staff who complete the consent receive the training. there will be a certificate of completion when training is completed.
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