Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information in four of ten client records.
The findings included:
Ten client records requiring an informed and voluntary consent from the client for the disclosure of information were reviewed on June 23, 2014. The facility failed to obtain an informed and voluntary consent from the client; including the specific information to be disclosed, the purpose of disclosure, dated signature of client, and dated signature of witness in client records # 3, 5, 6 and 10.
Client # 3 was admitted into treatment on February 27, 2014 and was discharged on May 28, 2014. A consent to release information to the primary care physican failed to include the specific information to be disclosed, and a dated signature of the client and the witness. Consent to release information forms for a D/A Commission, a Board of Assistance and a funding source do not include a dated signature of the client and the witness.
Client # 5 was admitted into treatment on April 7, 2014. Consent to release information forms for D/A Commission, a Board of Assistance and a funding source do not include a dated signature of the client and the witness.
Client # 6 was admitted into treatment on January 9, 2014. Four consent to release information forms for another client were in this client record. A consent to release information form for transportation which was signed on May 9, 2014, did not include accurate information for specific information to be disclosed or an accurate purpose of disclosure.
Client # 10 was admitted into treatment on March 27, 2014. Consent to release information forms for a D/A Commission, and a primary care physician do not include a dated signature of the client and the witness.
The outpatient director confirmed the findings.
|
Plan of Correction
The Outpatient Director will retrain all applicable staff on completing releases accurately and completely by July 30, 2014. All current releases will be reviewed by July 30, 2014 and corrected with consumer at next scheduled appointment to ensure meeting confidentiality guidelines. Random chart audits will be conducted monthly to ensure compliance. |