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 contained in the client record in four of seven records.Client #2 was admitted on March 12, 2021. Four consents to release information dated March 12, 2021 had "verbal consent due to COVID 19" written in lieu of a client signature.Client #4 was admitted on March 9, 2020 and discharged October 19, 2021. Three consents to release information dated March 4, 2021 and one consent dated May 7, 2021 had "verbal consent due to COVID 19" written in lieu of a client signature.Client #5 was admitted on October 9, 2020 and discharged June 28, 2021. Four consents to release information dated October 9, 2020 had "verbal consent due to COVID 19" written in lieu of a client signature.Client #6 was admitted on October 13, 2020 and discharged June 1, 2021. Five consents to release information dated October 13, 2020 had "verbal consent due to COVID 19" written in lieu of a client signature.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction for 709.28 (c) (4) LICENSURE Confidentiality:
In the event of another Pandemic safety threat, or any other state mandated order providing it necessary to provide services through telehealth, the FSCAS Drug & Alcohol Clinical Staff will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. When mandates indicate the need for Telehealth services, the D&A clinical staff will obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent will be in writing and include, but not be limited to dated signature of client or guardian. The consent will be obtained by the following means:
- Through use of an encrypted secured email where the consent form can be scanned, signed and scanned back.
- Mailed through use of the United States Postal System. A postage paid stamped return envelope will be included with the informed and voluntary consent form. The form will be signed and returned in the enclosed postage paid envelope.
- Or when possible, in-person signatures will be obtained.
The policy above shall be reflected in the Drug & Alcohol Program's Telehealth policy. As of December 8, 2021, an update to the D & A Program's Telehealth policy was completed. All FSCAS Drug & Alcohol staff will attend the December 17, 2021 Clinical Supervision meeting and where this policy will be reviewed. In addition to the all staff meeting, the Clinical Supervisors will review and address any questions during their weekly supervision during the week of December 8th through the 17, 2021.
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