Observations
Based on a review of client record, the facility failed to obtain informed and voluntary consents record reviewed.
The findings include:
One client records was reviewed on December 1, 2015. The facility failed to document informed and voluntary consents #1.
Client #1 - Progress note dated August 13, 2015 had documentation that the facility called the client's dentist to verify his appointment. The facility failed to obtain an informed and voluntary consent for the client's dentist.
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Plan of Correction
On the date in question, the program wanted to verify the patient dental appointment; patient had continuously miss individual as well as group session and would always make up different excuses that were unfounded. The patient was disputing that he had a dental appointment and suggested that the program call the dental office to verify his appointment. The patient provides the Program Director, in the presences of the Executive Director, his counselor and paramour, verbal consent to call his dental office. Client #6 even dials the dental office phone number. In respect to the patient the facility never stated where they were calling from, other then stating that they were calling to verify client #6 appointment for today. THW never was disclosed any information as it relates to client #6 or his treatment with THW. The dental office stated that client #6 had no appointments schedule for today. Again another lie that the clinic was able to catch client #6 in, which includes a long list different issues with the client #6.
As a Plan Of Correction (POC), The Healing Way (THW) affective immediately and moving forward Program Director will ensure that all staff will obtain writing informed voluntary consent to outreach and call any clients doctors, lawyers, dentist, family members or any organization that the client would like for the program to contact. THW will no longer rely solely on a verbal consent made by any clients. The consent can be initiated by a client with a verbal, however; THW will also mandate said client to also sign a writing consent to accompany their verbal consents. Clients will continue to be able to revoke consents verbally or in writing form.
The Program Director will conduct an in-house training on PA 255.5 to review and discuss informed consent and limitations for information disclosure from a patient record to governmental agencies, the criminal justice system, medical doctor and all third party payers. This training will take place on January 11, 2016, upon the return of all staff members from holiday vacation. For charts identified as being deficient during this inspection, we will have the patients sign new release forms allowing for only the information which can be released under PA 255.5 to governmental agencies, criminal justice system, probation, DHS or child protective services, doctors and third party payers.
The previous release forms, which did not comply with PA 255.5, will be revoked at the same time and both copies will remain in the patient charts.
Additionally, compliance with PA 255.5 will be monitored via the monthly quality record review by the program Director, as well as during supervision with counselors. The Program Director is in charge of making sure that the training gets completed as well as the staffs are applying the PA 255.5 code to their release of information.
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