Observations
The facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in three of seven client records reviewed during the annual licensing inspection conducted on February 15 - 16, 2017.
A consent to release information was not documented for the client's primary care physician and the facility disclosed by letter the client's name, drug and alcohol symptoms and treatment recommendations in the following client records.
Client # 1 was admitted into treatment on August 23, 2016. The disclosure occurred on August 25, 2016.
Client # 7 was admitted into treatment on July 21, 2016 and discharged on January 6, 2017. The disclosure occurred on July 22, 2016.
A consent to release information was not documented for a government agency and the facility disclosed by email and letter the client's name and summary of progress in the following client record.
Client # 5 was admitted into treatment on May 13, 2016 and discharged August 15, 2016. The disclosures occurred on August 1 and August 3, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Quality & Compliance Specialist will meet with the Nurse Manager to review this regulation. Together, they will conduct a 30 minute training with medical department personnel on how to properly complete consent to release information forms, the purposes for doing so, and the importance of receiving signed consent from the client prior to releasing information.
During the March 2017 Team Meetings, the Program Manager and Quality & Compliance Specialist will conduct a 30 minute training with direct care employees and supervisors on how to properly complete consent to release information forms and the purposes for doing so.
During the April 2017 Counselor Meetings, the Clinical Director and Quality & Compliance Specialist will conduct a 30 minute refresher session with Counselors, Counselor Assistants and Treatment Supervisors on how to properly complete consent to release information forms and the purposes for doing so.
The Quality & Compliance Specialist will complete quarterly chart audits on a random sample of client charts to verify consent to release information forms are completely and accurately documented.
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