Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one out of thirteen records reviewed.
Client #7 was admitted on February 20, 2026, and was discharged on March 19, 2026. There was no documentation that the facility obtained an informed and voluntary consent for an insurance provider; however, there is documentation in the client record that the facility sent paperwork to the insurance provider on February 27, 2026.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility acknowledges the finding related to confidentiality documentation under § 709.28(c). Staff will receive continued training regarding confidentiality requirements, releases of information, and proper documentation procedures to ensure informed and voluntary client consent is obtained prior to the disclosure of any client information. The facility will reinforce adherence to existing policies and procedures governing releases of information and confidentiality practices. Supervisory staff will conduct ongoing chart reviews to monitor compliance and ensure all required consent forms are properly completed and maintained in the client record prior to communication with insurance providers or other external entities. |