Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information contained in the client record in one of seven applicable client records reviewed.
Client # 4 was admitted to the partial hospitalization activity on April 3, 2025 and was discharged on April 26, 2025. There was evidence of a disclosure to the parole officer on April 17, 2025; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The client that was missing the release of information was discharged from treatment and this cannot be corrected.
We believe that that the missing release of information was revoked by the client however, it was never documented in the client's record.
The Project Director will conduct training for clinical personnel regarding releases of information. The in-service will review the legal and ethical obligations of obtaining consent to release information and how to document client records when a client revokes a release of information. This will be conducted by the Project Director and completed by 12-31-2025
Effective immediately, the Facility Director will review the charts at least Biweekly to ensure that all staff is completing informed consents for all external contacts according to State, Federal, and program guidelines.
By 12-31-2025, the clinical supervisor will also conduct supervision that will review releases of information and how to indicate / document release of information that are revoked.
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