Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information contained in the client record in one of seven client records.
Client #4 was admitted on October 20, 2022 and discharged on June 15, 2023. There was no documentation of an informed and voluntary consent for the funding source with the purpose of obtaining funding in client record #4. It was confirmed with facility staff that services were billed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 08/02/2023, Facility Director updated specific consent to also include the wording Bill for Services. This will be monitored by ongoing chart audits. |