Observations
Based on a discussion with the facility director, a review of the consent to release information form and a review of client records on May 13, 2010, the facility failed to document that a copy of the consent to release information form was offered to and/or accepted or rejected by the client.
The findings include:
Six client records were reviewed May 13, 2010. Five records were reviewed for documentation that the consent to release information form had been offered to the client and accepted or rejected. Records #1, 2, 3, 4, and 5 did not contain documentation that the client was offered a copy of the consent form and if it was accepted or rejected.
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Plan of Correction
The Facility Director will review the client Releases of Information form and modified to included a box indicating that the client has been offered a copy and if they rejected or accepted it. The form will then be sent for approval from Hospital administration and sent out for printing. While waiting for the form to be updated, the counselors will document in the chart that a copy was offered and if it was accepted or rejected. This will take place immediately as of 5/20/10. |